High-Risk Postpartum

84. A client on the postpartum unit has been diagnosed with deep vein thrombosis. The following titration schedule is included in the client's orders: If INR is 1: administer 7500 units heparin subcutaneously (sc) If INR is 1.1 to 2: administer 5000 units heparin sc If INR is 2.1 to 3: administer 2500 units heparin sc If INR is 3: administer 0 units heparin sc The client's INR is 2.6. How many mL of heparin will the nurse administer if the available concentration of heparin is 5000 units per 0.2 mL? __________ mL.

0.1 mL

52. A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply. 1. Look up the client's blood type in the chart. 2. Check the client's arm bracelet. 3. Check the blood type on the infusion bag. 4. Obtain an infusion bag of dextrose and water. 5. Document the time the infusion begins.

1, 2, 3, and 5 are correct. 1. The nurse must check the client's blood type. 2. The nurse must check the client's name by checking the bracelet and asking the client her name. 3. The nurse must compare the client's blood type with the blood type on the infusion bag. 4. The nurse must obtain an infusion of normal saline, not dextrose and water. 5. The time the infusion begins and ends must be documented. TEST- TAKING TIP: The potential for blood transfusion incompatibility is very real. It is essential, therefore, that two health care practitioners check simultaneously to make sure that the client is receiving the correct blood. If any sign of a reaction should develop, the transfusion should be stopped immediately. Only normal saline solution is used as a solution immediately before or after blood administration. Dextrose in water will hemolyze the red blood cells. In addition, a special filtered infusion set must be used.

17. A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform? 1. Cover the wound with sterile wet dressings. 2. Notify the surgeon. 3. Elevate the head of the client's bed slightly. 4. Flex the client's knees.

1. After the surgeon is notified, the nurse should stay with the patient while another staff member gathers supplies, including a suture removal kit and personal protective equipment as well as sterile saline solution and a large syringe. 2. The highest priority action is to notify the surgeon. 3. The nurse should elevate the client's bed slightly. 4. The nurse should flex the client's knees slightly. TEST-TAKING TIP: Positioning of the client is important since the nurse wants to take as much stress off the incision as possible. If the surgeon is delayed, and the dehiscence is significant, the nurse must keep the intestines moist by placing sterile dressings that have been wet with sterile saline, over the area.

73. A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take? Select all that apply. 1. Swaddle the baby in a baby blanket. 2. Discuss funeral options for the baby. 3. Encourage the couple to try to get pregnant again soon. 4. Ask the couple whether or not they would like to hold the baby. 5. Advise the couple that the baby's death was probably for the best.

1, 2, and 4 are correct. 1. This is an appropriate action. The baby should be handled with respect. 2. This is an appropriate action. Funerals help clients to achieve closure and to provide others with a means of acknowledging the baby's death. 3. This is inappropriate. The couple must grieve the loss of this child. 4. This is an appropriate action. Although there are some clients who will decline to hold their babies, the action is very important for those who accept the opportunity. 5. This action is inappropriate. Stating that the loss of a baby is for the best is very demeaning and unfeeling. TEST-TAKING TIP: Clients must be encouraged and assisted through the process of grieving and mourning their babies. In addition, since most women will remain on the obstetric unit, there must be a mechanism, like a specific picture placed on the woman's door, for communicating to every department in the hospital, from nursing to housekeeping to dietary, and so on, that the client has had a fetal death.

38. A client is 1-day post-cesarean delivery for eclampsia. The client is receiving 5% dextrose in 1 ⁄2 normal saline IV at 125 cc/hr and magnesium sulfate IV via infusion pump. Which of the following laboratory values should the nurse report to the surgeon? 1. Serum magnesium 7 mg/dL. 2. Serum sodium 136 mg/dL. 3. Serum potassium 3.0 mg/dL. 4. Serum calcium 9 mg/dL.

1. A magnesium level of 7 mg/dL is therapeutic. This is an expected level. 2. The serum sodium level is normal. 3. The serum potassium is below normal. The nurse should report the finding to the physician. 4. The serum calcium is normal. TEST-TAKING TIP: The test taker should be familiar with the normal values of commonly tested electrolytes. Although the normal magnesium level is 1.8 to 3.0 mg/dL, magnesium sulfate is being administered to raise the level in the client's blood stream. The medication, which is an anticonvulsant, is being administered to prevent further seizures. The potassium level, however, is well below normal.

83. A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby's and mother's infection? 1. Staphylococcus aureus. 2. Streptococcus pneumonia. 3. Escherichia coli. 4. Candida albicans.

1. Staphylococcus aureus is the most common bacteria to cause mastitis. 2. Streptococcus pneumoniae is a major cause of pneumonia. 3. Certain strains of Escherichia coli cause severe gastritis. 4. The baby and mother are infected with Candida albicans. TEST-TAKING TIP: When breastfeeding babies develop thrush, the mothers are at high risk for developing a yeast infection of the breast. Since they are both infected, it is critical that they be treated simultaneously for a minimum of 2 weeks. If they are not treated aggressively, they will continue to reinfect each other.

19. The nurse is discharging four Rh-negative clients from the maternity unit. The nurse knows that further teaching is needed when the client who had which of the following deliveries asks why she has not received her RhoGAM? 1. Abortion at 10 weeks' gestation. 2. Fetal demise at 24 weeks' gestation. 3. Birth of Rh-negative twins at 35 weeks' gestation. 4. Delivery of a 40-week-gestation Rh-positive baby.

1. The client should receive a RhoGAM injection after a spontaneous abortion. 2. The client should receive a RhoGAM injection after a fetal demise. 3. The client does not need a RhoGAM injection after the delivery of Rh-negative twins. 4. The client should receive a RhoGAM injection after birth of an Rh-positive baby. TEST-TAKING TIP: RhoGAM, or Rh immune globulin, is administered to pregnant women at 28 weeks' gestation; after any invasive procedure, like an amniocentesis; after a preterm disruption of a pregnancy, like abortion or placental previa bleed; and after the delivery of an Rh infant. Because Rh-negative infants carry no Rh antigen, it is unnecessary to administer RhoGAM to their Rh-negative mothers

26. A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for last 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.

1. This output is below the accepted minimum for 8 hours. 2. This weight decrease following delivery is within normal limits. 3. A 2% drop in hematocrit is within normal limits. 4. This pulse rate is within normal limits. TEST-TAKING TIP: The nurse must divide the amount of urine output by the number of hours. The output in the scenario is equal to 25 cc/hr. This is well below the accepted output of 30 cc/hr. Plus, because this is a postpartum client, the nurse would expect high urinary outputs. Postpartum clients often have slowed heart beats.

50. A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose? 1. Vitamin K. 2. Protamine. 3. Vitamin E. 4. Mannitol.

1. Vitamin K is the antidote for Coumadin (warfarin) overdose, not for heparin overdose. 2. Protamine is the antidote for heparin overdose. 3. Vitamin E is not correct. 4. Mannitol is not correct. TEST-TAKING TIP: When heparin is administered, clients must be monitored carefully for signs of hemorrhage. Protamine is the antidote for heparin overdose. On the other hand, the antidote for Coumadin, another medication often administered to clients with DVT, is vitamin K.

40. A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk? 1. Hemorrhage. 2. Stroke. 3. Endometritis. 4. Hematoma.

1. When a client has DVT she is clotting excessively. She is not at high risk for hemorrhage. 2. The client is at high risk for stroke if a clot should travel to the brain through the vascular tree. 3. The client is not at high risk for endometritis if she has DVT. 4. The client is not at high risk for hematoma if she has DVT. TEST-TAKING TIP: The test taker could deduce the answer to this question by determining the etiology of each of the problems. The only complication that is caused by a clot, which is the same etiology as the DVT, is a stroke.

69. A client who has been diagnosed with deep vein thrombosis has been ordered to receive 12 units heparin/min. The nurse receives a 500-mL bag of D5W with 20,000 units of heparin added from the pharmacy. At what rate in mL/hr should the nurse set the infusion pump? __________ mL/hr.

18 mL/hour

37. Cloxacillin 500 mg by mouth four times per day for 10 days has been ordered for a client with a breast abscess. The client states that she is unable to swallow pills. The oral solution is available as 125 mg/5 mL. How many mL of medicine should the woman take per dose? ______ mL per dose.

20 mL per dose

58. A client is receiving an IV heparin drip at 16 mL/hr via an infusion pump for a diagnosis of deep vein thrombosis. The label on the liter bag of D5W indicates 50,000 units of heparin have been added. How many units of heparin is the client receiving per hour? __________ units per hour.

800 units/hour

39. The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching in the hospital was successful? 1. The client is breastfeeding her baby every two hours. 2. The client is using a diaphragm for family planning. 3. The client is taking her temperature every morning. 4. The client is seeking care for a recent weight loss.

1. Breastfeeding is contraindicated when a mother is HIV positive. 2. It is recommended that HIV-positive clients use condoms for family planning. 3. It is unnecessary to take her temperature every morning. If she should develop a fever, she should seek medical assistance as soon as possible, however. 4. The client should seek care for a recent weight loss. This may be a symptom of full-blown AIDS. TEST-TAKING TIP: Although obstetric clients who enter the hospital are usually aware of their HIV status, the nurse must still review the actions clients should take after discharge. These actions include taking all medications, bottle-feeding rather than breastfeeding, and reporting any changes in health, like weight loss or the appearance of thrush.

3. A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? 1. Hyperthermia, vomiting, and diarrhea. 2. Hypotension and respiratory collapse. 3. Anasarca and fluid volume overload. 4. Palpitations, anxiety, and insomnia.

1. Hemabate can cause nausea, vomiting, diarrhea, and hyperthermia. 2. Hypotension and respiratory collapse are not associated with Hemabate. 3. Anasarca and fluid volume overload are not associated with Hemabate. 4. Palpitations, anxiety, and insomnia are not associated with Hemabate. TEST-TAKING TIP: Hemabate is an oxytocic agent that acts on the myometrial tissue of the uterus. During the postpartum it acts directly at the site of placental separation to stop uncontrolled bleeding. Hemabate is a type of prostaglandin.

6. A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104. 2. Urinary output 240 cc/12 hr. 3. Blood pressure 160/120. 4. Temperature 100ºF

1. It is unlikely that an apical heart rate of 104 is responsible for the client's changes. 2. The urinary output is the likely cause of the client's changes. 3. It is unlikely that a blood pressure of 160/120 is responsible for the client's changes. 4. It is unlikely that a temperature of 100ºF is responsible of the client's changes. TEST-TAKING TIP: The hourly output for this client is 20 cc/hr. This is well below the minimum urinary output of 30 cc/hr. Since the medication is excreted via the kidneys, when a client's output is low, the concentration of the medication can increase to toxic levels in the bloodstream. This client is exhibiting signs of magnesium toxicity.

9. The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug? 1. Monitor the urinary output hourly. 2. Supervise while the woman holds her newborn. 3. Position the woman slightly elevated on her left side. 4. Ask any visitors to leave the room.

1. It is unnecessary to monitor the client's hourly urinary output. 2. This is an appropriate action. 3. It is unnecessary for the client to be placed in this position. 4. It is unnecessary for visitors to leave the client's room TEST-TAKING TIP: Benadryl is an antihistamine. One of the common side effects of Benadryl is sedation. It is very likely that this client will fall asleep while holding the baby. The nurse, therefore, should supervise the mother while she holds her baby.

8. The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement? 1. Maintain client in left lateral recumbent position. 2. Teach sitz bath use on second postoperative day. 3. Perform active range of motion exercises until ambulating. 4. Assess central venous pressure during first postoperative day.

1. Postoperative C/section clients should turn every 2 hours to prevent stasis of their lung fields. 2. Sitz baths are rarely ordered for C/section clients. 3. Active range of motion exercises will help to prevent thrombus formation in C/section patients. 4. Central venous pressure is rarely assessed in C/section clients. TEST-TAKING TIP: Clients, whether they have intermittent positive pressure boots ordered or not, should be advised actively to move their legs at least a few times each hour. If the client exercises, she will be much less likely to develop deep vein thrombosis.

80. A nurse is assessing a 1 day-postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10 point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic.

1. The client should be assessed by her health care practitioner. 2. The client may need a sitz bath, but should be assessed first. 3. It is unlikely that this client has a hidden laceration since her lochial flow is normal. 4. The client may benefit from a narcotic, but should be assessed first. TEST-TAKING TIP: This client is complaining of an excessive amount of pain after having received a relatively large dose of ibuprofen. Because the perineum is edematous, the lochial flow is normal, and the pain level is well above that expected, the nurse should suspect that the client has developed a hematoma. The client should be assessed by her health care provider.

51. A client, who had no prenatal care, delivers a 10 lb 10 oz-baby boy whose serum glucose result 1 hour after delivery was 20 mg/dL. Based on these data, which of the following tests should the mother have at her 6-week postpartum check up? 1. Glucose tolerance test. 2. Indirect Coombs' test. 3. Blood urea nitrogen (BUN). 4. Complete blood count (CBC).

1. The client should have a glucose tolerance test done at about 6 weeks' postpartum. Women who give birth to hypoglycemic and/or macrosomic babies are at increased risk of developing type 2 diabetes. 2. There is no indication in the scenario of Rh incompatibility that would require that an indirect Coombs' test be done. 3. There is no indication in the scenario that this client has impaired kidney function and should have a BUN done. 4. There is no indication in the scenario that this client should have a CBC done. There is no indication of anemia or infection. TEST-TAKING TIP: The baby born to this mother is hypoglycemic and is macrosomia. The most common cause of these two neonatal complications is maternal diabetes. It is recommended that mothers who are diabetic during pregnancy— that is, gestational diabetics—be assessed for type 2 diabetes at about 6 weeks' postpartum.

36. The nurse is circulating on a cesarean delivery of a G5P4004. All of the client's previous children were delivered via cesarean section. The physician declares after delivering the placenta that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2000 mL. 2. Blood pressure of 160/110. 3. Jaundice skin color. 4. Shortened prothrombin time.

1. The client with a placenta accreta is high risk for a large blood loss. 2. Placenta accreta is not related to a hypertensive state. 3. Placenta accreta is not related to the development of jaundice. 4. The nurse would not expect to detect a shortened prothrombin time when a client has a placenta accreta. TEST-TAKING TIP: A placenta accreta's chorionic villi burrow through the endometrial lining into the myometrial lining. Separation of the placenta from the uterine wall is severely hampered. Clients often lose large quantities of blood, and it is not uncommon for the physician to have to perform a hysterectomy to control the bleeding. Clients who have had multiple uterine scars are especially at high risk for this problem. If the test taker were unfamiliar with placenta accreta, he or she could deduce the answer since the placenta is highly vascular and only one answer referred to a vascular issue. In addition, the average blood loss during a cesarean delivery is 1000 cc

30. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 1. Hallucinations. 2. Polyphagia. 3. Induced vomiting. 4. Weepy sadness.

1. The client with postpartum psychosis will experience hallucinations. 2. Clients with diabetes mellitus, not postpartum psychosis, are polyphagic. 3. Clients with bulimia induce vomiting. 4. Clients with postpartum blues and/or postpartum depression are weepy and sad. TEST-TAKING TIP: Clients who have been diagnosed with postpartum psychosis have a psychiatric disease. They experience hallucinations, usually auditory, including voices that may tell them to kill their babies

13. Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

1. The client would be expected to complain of pain. 2. The nurse would not expect to see bleeding. 3. The nurse would not expect to note warmth. 4. The nurse would not expect to see redness. TEST-TAKING TIP: A hematoma is a collection of blood under the skin. Although hematomas are usually simple bruises, large collections of blood can occur. Because the blood is trapped under the skin, the most common symptom is pain from the blood pressing on the pain sensors.

44. A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? 1. Engorgement. 2. Mastitis. 3. Blocked milk duct. 4. Low milk supply.

1. The nurse would not expect to see engorgement. 2. The nurse would not expect to see mastitis. 3. The nurse would not expect to see a blocked milk duct. 4. The nurse would expect that the woman would have a low milk supply. TEST-TAKING TIP: The placenta produces the hormones of pregnancy, including estrogen and progesterone. When placental fragments are retained, those hormones are still being produced. Estrogen inhibits prolactin, which is the hormone of lactogenesis, or milk production. Women who have retained placental fragments, therefore, often complain of an insufficient milk supply for their babies.

71. The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen (hPL). 4. Human chorionic gonadotropin (hCG).

1. The drop in estrogen is not related to the glucose level. 2. The drop in progesterone is not related to the glucose level. 3. The drop in human placental lactogen (hPL) is related to the glucose level. 4. The drop in human chorionic gonadotropin is not related to the glucose level. TEST-TAKING TIP: The hormone hPL is an insulin antagonist. Throughout pregnancy, the insulin needs of type 1 diabetics rise incrementally as the levels of hPL in the bloodstream rise. Once the placenta is birthed, however, the levels drop precipitously. As a result, it is not uncommon for the glucose levels of type 1 diabetics to be within normal limits for a day or so after delivery—as seen in this client.

11. A rubella nonimmune, breastfeeding client has just received the rubella vaccine. Which of the following side effects should the nurse warn the client about? 1. The baby may develop a rash a week after the shot. 2. The baby may temporarily reject the breast milk. 3. The mother's milk supply may decrease precipitously. 4. The mother's joints may become painful and stiff

1. The mother, not the baby, may develop a macular rash a week after the shot. The baby will be unaffected. 2. There is no evidence to suggest that babies whose mothers have received the rubella vaccine reject their mother's breast milk. 3. There is no evidence to suggest that the mother's breast milk supply will drop. 4. One out of 4 women complains of painful and stiff joints after receiving the injection. TEST-TAKING TIP: Even though the benefits of receiving immunizations far outweigh the side effects of the medicines, anyone who receives a vaccine should be advised of the potential complications. It is especially important for mothers who are taking home newborn infants to receive anticipatory guidance regarding these changes and to be told that the baby's health will not be compromised.

33. A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6˚F, P 72, R 20, BP 150/100, and her reflexes are 4. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes.

1. The results are not normal. This client's blood pressure is markedly elevated and the client is hyperreflexic. 2. The nurse should notify the physician of the signs of preeclampsia. 3. There is no need to discontinue the intravenous infusion. 4. The findings are consistent with signs of preeclampsia. It would be inappropriate to wait fifteen minutes to verify the results. TEST-TAKING TIP: The hypertensive illnesses of pregnancy can develop at any time after 20 weeks' gestation through about 2 weeks' postpartum. This client is exhibiting a late onset of preeclampsia— markedly elevated blood pressure and hyperreflexia. The physician should be notified of the changes

45. The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time? 1. Advise the woman to wash the area with soap to prevent mastitis. 2. Provide the woman with a tube of topical lanolin. 3. Remind the woman that the baby can become sick if he drinks the blood. 4. Get the woman an order for a topical anesthetic.

1. The woman should not wash with soap. Soaps destroy the natural lanolins produced by the body. 2. A small amount of lanolin should be applied to the nipple after each feeding. 3. The baby will not become sick from the blood. The woman should be warned that he may spit up digested and/or undigested blood after the feeding, however. 4. Topical anesthetics are not used on the breasts. The woman could receive an oral analgesic, however. TEST-TAKING TIP: Using lanolin on the breasts is a type of moist wound healing. The lanolin is soothing and allows the nipple to heal without a scab developing on the surface of the nipple. Mothers are often very concerned about their babies swallowing the blood. Ingesting the blood does not adversely affect the babies unless, of course, the mother is HIV positive or carries another blood-borne virus.

16. The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? 1. Ineffective lactogenesis. 2. Dysfunctional parenting. 3. Wound dehiscence. 4. Projectile vomiting.

1. There is nothing in this client's history that would indicate that she could not produce breast milk. 2. There is nothing in this client's history that would indicate that she is at high risk for dysfunctional parenting. 3. This client is at high risk for wound dehiscence. Her wound healing may be impaired because of her diabetes and because of her obesity. 4. There is nothing in this client's history that would indicate that she is at high risk for projectile vomiting. TEST-TAKING TIP: The fact that this client is postoperative cesarean section is irrelevant. This question could be written by a surgical nursing professor rather than a parent-child nursing professor. The important pieces of information needed correctly to answer this question are that this client is obese and a type 1 diabetic and that she has had surgery.

20. In which of the following situations should a nurse report a possible deep vein thrombosis (DVT) even when the woman has a negative Homan's sign? 1. The woman complains of numbness in the toes and heel of one foot. 2. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. 3. One of the woman's calves is swollen, red, and warm to the touch. 4. The veins in the ankle of one of the woman's legs are spider-like and purple.

1. These findings are not consistent with a diagnosis of DVT. They may be due to a resolving epidural anesthesia. 2. These findings are normal. Many women complain of leg cramping. 3. Even with a negative Homan's sign, these findings—swelling, redness, and warmth—indicate presence of a DVT. 4. These findings are normal. Many women develop spider veins during their pregnancies. TEST-TAKING TIP: When a client has a DVT, Homan's signs are positive only about 30% of the time. The nurse should always assess for other signs of thrombosis: pain, warmth, redness, and edema. The signs are usually unilateral. It is especially important for the nurse to refrain from palpating the calf too deeply because it is possible to dislodge a clot and cause a pulmonary embolism.

22. A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client? 1. Strongly advise the client to breastfeed her baby. 2. Perform hourly incentive spirometer respiratory assessments. 3. Suggest that the nursery nurse feed the baby in the nursery. 4. Provide the client with supervised instruction on baby care skills.

1. This action is inappropriate. Breastfeeding is contraindicated when the mother uses illicit drugs. 2. This action is unnecessary. There is nothing in the scenario that implies that the client is having respiratory difficulties. 3. This action is inappropriate. Rather the nurse should encourage mother/baby interaction and provide the mother with parenting education. 4. Providing instruction on baby care skills is a very important action for the nurse to perform. TEST-TAKING TIP: Babies of mothers who are addicted to illicit drugs go through a withdrawal period and, because of the addiction, often have very disorganized behavior patterns. The nurse must provide guidance for the primipara regarding care of her difficult infant, especially because the client has already exhibited poor judgment. In addition, of course, the nurse must report the family to child protective services.

81. A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible.

1. This action is inappropriate. The woman should apply warm soaks to the breast. 2. The action is appropriate. The woman should breastfeed frequently. 3. The woman should be discouraged from weaning. 4. It is unnecessary for the client to notify the pediatrician. The baby's health is not in jeopardy TEST-TAKING TIP: Mastitis is a breast infection. Usually only one duct system is affected by the bacteria. If the mother were to wean abruptly, milk stasis would occur, the bacteria would proliferate, and a breast abscess is likely to develop. The mother should feed her baby frequently, use warm soaks to promote milk flow, and notify her obstetrician. Antibiotics are usually prescribed to eradicate the bacteria.

31. The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? 1. Gently massage the areas toward the nipple especially during feedings. 2. Apply ice to the areas between feedings. 3. Bottlefeed for the next twenty-four hours. 4. Apply lanolin ointment to the areas after each and every breastfeeding.

1. This answer is correct. She should gently massage the area toward the nipple. 2. The woman should apply warm soaks, not ice. 3. The woman should be advised to feed her baby frequently at the breast. She should not be advised to bottlefeed. 4. The woman should apply lanolin (Lansinoh) to sore or cracked nipples, not for a problem of tender hard nodules. TEST-TAKING TIP: A client who palpates a tender, hard nodule in her lactating breast is experiencing milk stasis. The stasis may be related to a blocked milk duct. It is very important that the woman gently massage the nodule while applying warm soaks and/or feeding her baby to prevent mastitis from developing.

77. A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis.

1. This client is high risk for uterine atony. 2. The client is not at high risk for hypoprolactinemia. 3. The client is not at high risk for infection. 4. The client is not at high risk for mastitis. TEST-TAKING TIP: The uterus of a woman who delivers a macrosomic baby has been stretched beyond the usual pregnancy size. The muscle fibers of the myometrium, therefore, are stretched. After delivery the muscles are unable to contract effectively in order to stop the bleeding at the placental separation site.

35. The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby with visible defects. Which of the following actions by the nurse is appropriate? 1. Discourage the parents from naming the baby. 2. Advise the parents that the baby's defects would be too upsetting for them to see. 3. Transport the baby to the morgue as soon as possible. 4. Give the parents a lock of the baby's hair and a copy of the footprint sheet.

1. This is inappropriate. Naming the baby is a means of acknowledging both the existence and the death of the baby. 2. This is inappropriate. Client's imaginations of what the baby looks like are often much worse than the reality. 3. This is inappropriate. The couple should be provided time to be with their baby before transporting the baby to the morgue. 4. This is appropriate. The small mementos will provide the couple with something tangible to remember the pregnancy and baby by. TEST-TAKING TIP: It is very difficult for parents who have delivered a fetal demise. The only contact they have had with the baby is through the pregnancy. Small mementos, such as a picture, lock of hair, or baby bracelet, provide the parents with tangible remembrances of the baby.

1. A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time? 1. "Monitor your blood glucose five times a day until your 6-week check-up." 2. "I will teach you how to inject insulin before you are discharged." 3. "Daily exercise will help to prevent you from becoming diabetic in the future." 4. "Your baby should be assessed every 6 months for signs of juvenile diabetes."

1. This is unnecessary. Gestational diabetic clients need not assess their blood glucose levels during the postpartum. 2. This is unnecessary. Gestational diabetic clients need not inject insulin during the postpartum. 3. This is an appropriate statement to make. 4. This is not appropriate. Babies rarely develop diabetes before age 2. Plus, juvenile diabetes is now called type 1 diabetes. TEST-TAKING TIP: Women who develop gestational diabetes are high risk for developing type 2 diabetes. They should be encouraged to eat healthy and to exercise in order to prevent the onset of the chronic disease or, at the very least, to delay its onset

15. A woman, who wishes to breastfeed, advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate? 1. Advise the woman that unfortunately she will be unable to breastfeed. 2. Examine the woman's breasts to see where the incision was placed. 3. Monitor the baby's daily weights for excessive weight loss. 4. Inform the woman that reduction surgery rarely affects milk transfer.

1. This may be true, but the mother may also be a successful breastfeeder. 2. This action can be helpful, but the placement of the incision will not necessarily determine the client's ability to breastfeed. 3. This action is very important. 4. This information is not accurate. Breast reduction surgery often does affect a woman's ability to breastfeed. TEST-TAKING TIP: During breast reduction surgery, fat tissue is removed from the breast. Because the breast is much smaller, the nipple must be moved to a new location. During these procedures, the client's mammary ducts may be ligated. If the ducts are severed, the woman will not be able to transfer the milk produced in her glandular tissue to the baby. The most objective means of assessing the milk transfer is by closely monitoring the baby's weights. Prefeed and postfeed weights as well as daily weights should be monitored.

60. Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order? 1. Postpartum clients are high risk for thrombus formation. 2. Post-cesarean clients are high risk for fluid volume deficit. 3. Postpartum clients are high risk for varicose vein development. 4. Post-cesarean clients are high risk for poor milk ejection reflex.

1. This rationale is correct. Because of an elevation in clotting factors, all postpartum clients are at high risk for thrombus formation. 2. The positive pressure boots improve blood return to the heart by preventing pooling of blood in the extremities. They are not applied to treat hypovolemia. 3. The rationale for the use of positive pressure boots is not related to varicose vein development. Varicose veins would, however, increase a client's potential for developing deep vein thrombosis. 4. The rationale for the use of positive pressure boots has nothing to do with a client's milk ejection reflex. TEST-TAKING TIP: The client in the scenario is post-cesarean section. The surgeon has ordered intermittent positive pressure boots for her because she is at high risk for thrombus formation and because she is on bed rest. Clients who deliver vaginally do not need the boots because they are able to ambulate immediately after delivery and, therefore, rarely experience pooling of blood in their extremities.

21. A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 3. Ask the woman if she would like the doctor to prescribe a sedative for her. 4. Remove the baby from the delivery room as soon as possible.

1. This response is inappropriate. The client is not thinking about a future pregnancy at this time. 2. This response is correct. 3. This response is not appropriate. The nurse should ask the client if she would like to see or hold the baby. 4. This response is not appropriate. The nurse should ask the client if she would like to see or hold the baby. TEST-TAKING TIP: The nurse should treat this baby with care and concern. Even though the baby has died he is still a valued child to the parents. The parents should be asked whether they would like to see or hold their baby. If they would, the nurse should help the parents to see the normalcy in their baby. Sedating a client only delays her inevitable grief.

68. A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding? 1. The mother states, "I'm so tired. Please feed the baby in the nursery for me." 2. The mother states, "Her eyes look like mine, but her chin is her Dad's." 3. The mother says, "We have decided to name her Sarah after my mother." 4. The mother says, "I breastfed her. I still need help swaddling her, though."

1. This statement by the mother may be a true statement, but it may communicate the mother's difficulty with accepting her baby. 2. This statement is an example of positive maternal bonding. 3. This statement is an example of positive maternal bonding. 4. This statement is an example of positive maternal bonding. TEST-TAKING TIP: Babies with defects are more likely to be victims of child abuse and neglect than are healthy, normal babies. Nurses must evaluate the bonding between the mother and her baby. If the nurse is concerned about the bonding relationship, he or she must monitor the mother's care and, if necessary, refer the family for a home care nurse evaluation and/or to child protective services

67. The nurse is caring for a client, G3P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make? 1. "Thank goodness. It could have been untreatable." 2. "I'm so happy that you have other children who are healthy." 3. "These things happen. They are the will of God." 4. "It is appropriate for you to cry at a time like this."

1. This statement is inappropriate. Any defect is devastating for the parents to accept. 2. This statement is inappropriate. This child is affected. That is all that matters. 3. This statement is inappropriate. The nurse must not impose his or her beliefs on the couple. 4. This statement is appropriate. Clients may need help or permission to express their grief. TEST-TAKING TIP: Nurses must be very careful how they speak with and care for clients who have had a baby that is less than perfect. Couples expect to birth perfect babies. When a baby who has a problem is born, the couple must grieve their "baby of fantasy," while they bond with and accept their "baby of reality."

18. The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0ºF, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings? 1. Temperature is elevated, a sign of infection. 2. Pulse is too low, a sign of vagal pathology. 3. Respirations are too low, a sign of medication toxicity. 4. Blood pressure is elevated, a sign of preeclampsia.

1. This temperature elevation does not indicate infection. 2. A low pulse rate is expected in the early postpartum period. 3. The respiratory rate of 12 is well below normal. Peripartum clients' respiratory rates average 20 rpm. 4. Although the systolic pressure is slightly elevated, a BP of 130/80 is within normal limits. TEST-TAKING TIP: Even though explanations are provided for each of the signs, the test taker must be able to determine which explanation is correct and which are erroneous. If the test taker consciously stops to think about each of the signs, before looking at the explanations, he or she is less likely to be swayed by a wrong answer.

32. A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful? 1. The mother's nipples are soft to the touch. 2. The baby swallows after every 5th suck. 3. The baby's pre- and postfeed weight change is 20 milliliters. 4. The mother squeezes her nipples during manual expression.

1. If the woman has manually removed milk from her breasts, her nipples will soften to the touch. 2. If the baby is latched well, he should swallow after every suck. 3. The nurse would expect the baby to transfer 60 mL or more at the feeding. 4. The mother should not squeeze her nipple. The area behind the areola should be gently compressed. TEST-TAKING TIP: This client is complaining of engorgement. The baby is having difficulty latching because the breast is inflamed, making the nipple tense and short. When the woman manually removes a small amount of the foremilk, the nipple becomes easier for the baby to grasp.

85. A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

1. Serial grip strengths can be performed to monitor a client for magnesium sulfate toxicity. 2. Kernig's assessment is performed when checking for nuchal rigidity in a client with meningitis. 3. Pupillary responses are performed when a client has had a head injury or is not responsive. 4. Apical heart rate checks are performed when a client has a cardiac disease or is receiving digoxin. TEST-TAKING TIP: The only accurate way to assess for magnesium toxicity is to do a serum magnesium level. Normal magnesium levels are 1.8 to 3.0 mg/dL. Therapeutic levels are 4 to 8 mg/dL. Reflex depression begins to appear when the levels reach 8 to 12 mg/dL. When levels rise to 15 mg/dL or higher, respiratory depression and, eventually, cardiac arrest occur. Hourly grip strengths performed with reflex assessments are excellent noninvasive assessments to monitor for neuromuscular blockage. If changes are noted, the nurse can notify the health care provider, who can order a stat magnesium level.

12. The nurse should expect to observe which behavior in a 3-week multigravid postpartum client with postpartum depression? 1. Feelings of infanticide. 2. Difficulty with breastfeeding latch. 3. Feelings of failure as a mother. 4. Concerns about sibling jealousy.

1. Feelings of infanticide are not consistent with the diagnosis of postpartum depression. 2. Difficulty latching babies to the breast is an independent problem from postpartum depression. Some mothers with depression are successful breast feeders, while some mothers who do not experience depression have difficulty latching their babies to the breast. 3. Mothers who experience postpartum depression often do feel like failures. 4. Concerns about sibling rivalry are not related to postpartum depression. TEST-TAKING TIP: If a mother who is diagnosed with postpartum depression does have difficulty latching her baby to the breast, she may view this as yet another example of her poor parenting skills. The difficulty itself, however, is unrelated to the diagnosis.

70. A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following laboratory values indicates that the medication is effective? 1. PT (prothrombin time): 12 sec (normal is 10-13 seconds). 2. INR (international normalized ratio): 2.5 (normal is 1.0-1.4). 3. Hematocrit 55%. 4. Hemoglobin 10 g/dL.

1. The PT is normal. For someone taking warfarin, the PT time should be prolonged 1.5 to 2.0 times normal. 2. The INR should be between 2 and 3. 3. The hematocrit is elevated. It should be within normal limits 4. The hemoglobin is below normal. It should be within normal limits. TEST-TAKING TIP: Coumadin interferes with the clotting of blood. The PT and/or INR will be monitored to determine whether or not the medication is effective. If the PT is more than 2 times normal or the INR is over 3, the client is at high risk for hemorrhage.

47. The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication? 1. Inhibit the mother's active immune response. 2. Aggressively destroy the Rh antibodies produced by the mother. 3. Prevent fetal cells from migrating throughout the mother's circulation. 4. Change the maternal blood type to Rh positive.

1. The goal of the injection of RhoGAM is to inhibit the mother's immune response. 2. Immune globulin is composed of antibodies. When a client receives RhoGAM, she receives passive antibodies to inhibit her immune response. 3. Passive antibodies cannot prevent the migration of fetal cells throughout the mother's bloodstream. 4. A client's blood type is determined by her DNA. RhoGAM cannot change a client's DNA. TEST-TAKING TIP: When a client receives RhoGAM, she receives passive Rh antibodies. If any Rh antigen is circulating in the mother's bloodstream, the antibodies will destroy it. As a result, there will be no antigen in the mother's body to stimulate her mast cells to have an active antibody response. In essence, therefore, RhoGAM is injected to inhibit the client's immune response.

59. A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved? 1. Moderate lochia flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus above the umbilicus.

1. A moderate lochia flow would indicate that the action was successful. 2. Decreased pain is not an expected outcome of uterine massage for uterine atony. 3. A stable postpartum blood pressure is not directly related to the action of uterine massage. 4. The expected outcome would be that the uterus is contracted at or below the umbilicus. TEST-TAKING TIP: Expected outcomes relate to specific nursing diagnoses that are developed after making an assessment. This client's uterine muscle was boggy. The nursing action taken—massage— related directly to the nursing assessment—atonic uterus—and the outcome—normal lochia—indicated that the action was successful.

54. A client is 3-days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective? 1. The client has had no seizures since delivery. 2. The client's blood pressure has dropped from 160/120 to 130/90. 3. The client's postoperative weight has dropped from 154 to 144 lb. 4. The client states that her headache is gone.

1. Hydralazine is administered as an antihypertensive, not specifically as an antiseizure medication. Magnesium sulfate is the drug administered as an anticonvulsant to women with eclampsia. 2. Hydralazine is an antihypertensive. The change in blood pressure indicates that the medication is effective. 3. The weight loss is secondary to fluid loss. 4. The hydralazine is not administered to treat a headache. TEST-TAKING TIP: Hydralazine is an antihypertensive medication. The goal, therefore, is for the blood pressure to drop. A change in BP from 160/120 to 130/90 is evidence of a therapeutic effect.

55. A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority? 1. Lochia is serosa. 2. Client cries throughout the visit. 3. Nipples are cracked. 4. Client yells at the baby for crying.

1. Lochia serosa at 2 weeks' postpartum is unusual, but it does not put the client or her baby in imminent danger. 2. This client is exhibiting signs of postpartum depression. This is a problem that must be remedied, but it does not put the client or her baby in imminent danger. 3. The client's cracked nipples do need intervention, but they do not put the client or her baby in imminent danger. 4. The client is exhibiting inappropriate behavior when she yells at the baby for crying. The nurse must make additional assessments to determine whether there is any other evidence of abuse or neglect. TEST-TAKING TIP: The baby is the most vulnerable member of the mother-infant dyad. Since the baby is completely dependent on the care of the mother, if the nurse discovers any behavior or other evidence that makes him or her suspicious of child abuse or neglect, he or she is obligated both morally and legally to report the situation. Clients who are experiencing postpartum depression usually perform baby care competently

2. A client is receiving a blood transfusion after the delivery of a placenta acreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion? 1. "My lower back hurts all of a sudden." 2. "My hands feel so cold." 3. "I feel like my heart is beating fast." 4. "I feel like I need to have a bowel movement."

1. Sudden lower back pain is a sign of a transfusion reaction. 2. This is not a sign of a transfusion reaction. The client may be nervous about receiving the blood. 3. This is not a sign of a transfusion reaction. The client may be nervous about receiving the blood. 4. This is not a sign of a transfusion reaction. The client is likely having a normal bowel movement. TEST-TAKING TIP: If the client is receiving the wrong type blood or is allergic to the blood, she will develop flank or kidney pain. Antibodies in the client's blood are likely destroying the donated blood. The transfusion should be stopped immediately and the reaction reported to the physician and to the blood bank

56. A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first? 1. Give two breaths. 2. Discontinue medications. 3. Call a code. 4. Check carotid pulse.

1. The nurse should call a code before beginning rescue breathing. 2. The nurse should call a code first and then discontinue the medication. 3. The nurse should call a code first. 4. The nurse should call a code before checking the carotid pulse. TEST-TAKING TIP: The nurse should call a code as soon as he or she discovers a client who is nonresponsive. Immediately after calling the code, the nurse should stop the medications, begin rescue breathing, and provide chest compressions, if necessary, until the code team arrives. Only after receiving an order to do so, should calcium gluconate, the antidote to magnesium sulfate, be administered.

62. A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period? 1. Infection. 2. Bloody urine. 3. Heavy lochia. 4. Rectal abrasions.

1. The nurse should monitor the client for signs of infection after the first 24 hours have past. 2. The client is not at high risk for bloody urine. 3. The client should be monitored carefully for heavy lochia. 4. The client is not at high risk for rectal abrasions. TEST-TAKING TIP: The key to answering this question is the time frame stipulated in the stem of the question—"the immediate postpartum period." There are two main maternal complications associated with forceps use—hemorrhage and infection. Hemorrhage usually occurs early, secondary to cervical, vaginal, or perineal lacerations. Infection usually develops later in the postpartum period secondary to contamination of the uterine cavity during the application of the forceps.

41. A mother, G4P4004, is 15 minutes postpartum. Her baby weighed 4595 grams at birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis.

1. This client is not especially at high risk for seizures. 2. The client should be monitored carefully for signs of postpartum hemorrhage. 3. This client is not especially at high risk for infection. 4. This client is not especially at high risk for thrombosis. TEST-TAKING TIP: An average sized baby weighs 2500 to 4000 grams. The baby in the scenario is macrosomic. As a result, the mother's uterus has been stretched beyond its expected capacity. The client is, therefore, at high risk for uterine atony, which could result in a postpartum hemorrhage

27. A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery complains of burning on urination. 2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO3 from cesarean delivery complains of firm and painful breasts.

1. This client must be assessed—she likely has a urinary tract infection (UTI)—but another client should be checked first. 2. This client must be assessed—although her blood loss is within normal limits— but another client should be checked first. 3. This client should be assessed first. The hemoglobin level is well below normal. 4. This client must be assessed—she is likely engorged—but another client should be checked first. TEST-TAKING TIP: The nurse must recognize normal and abnormal findings. For example, 500 mL blood loss is an expected loss during a vaginal delivery. A hemoglobin of 7.2 g/dL, however, is well below the normal of 12 to 15 g/dL. This client is likely exhibiting signs of hypovolemia, including tachycardia, fatigue, and dizziness. She should be assessed first.

34. A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O (negative), the baby's type is A (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate? 1. Advise the client to keep her physician appointment at the end of the week in order to receive her RhoGAM injection. 2. Carefully check the record to make sure that the RhoGAM injection was administered. 3. Notify the client that because her baby's Coombs' test was negative she will not receive an injection of RhoGAM. 4. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.

1. This response is incorrect. RhoGAM must be administered within 72 hours of delivery. 2. This response is correct. The nurse should not finalize an Rh (negative) client's discharge until the client has received her RhoGAM injection. 3. This response is incorrect. A negative direct Coombs' test means that no maternal antibodies were detected in the baby's circulatory system. The nurse would expect to detect a negative direct Coombs' test. 4. This response is unacceptable. Rh- (negative) clients should receive their RhoGAM injection before 72 hours' postpartum or by discharge, whichever is earlier. TEST-TAKING TIP: The administration of RhoGAM is the only way to prevent an Rh (negative) client's body from mounting a full antibody response to the delivery of an Rh (positive) baby. It is malpractice for a nurse to discharge the client before she receives her injection or to delay the injection beyond the 72-hour deadline

25. A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus? 1. Abdominal striae. 2. Oliguria. 3. Omphalocele. 4. Absent bowel sounds.

1. Abdominal striae are stretch marks. They are a normal side effect of pregnancy. 2. Oliguria is a complication that may develop after surgery, but it is not a symptom of paralytic ileus. 3. An omphalocele is a herniation of the intestines into the umbilical cord. It is sometimes seen in newborns. 4. An absence of bowel sounds may indicate that a client has a paralytic ileus. TEST-TAKING TIP: One of the complications of surgery and/or anesthesia is a paralytic ileus, the cessation of intestinal peristalsis. The client should be given nothing by mouth. Among other interventions, a nasogastric tube is usually inserted and attached to low suction.

23. A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediolateral episiotomy. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain.

1. Because the baby has Down syndrome, this is an appropriate nursing diagnosis, but it is not the highest priority diagnosis. 2. This is the priority nursing diagnosis. Because the baby is macrosomic, the client is high risk for uterine atony that could lead to heavy vaginal bleeding possibly resulting in fluid volume deficit. 3. Although the client is at high risk for infection, it is not highest priority. Infections take time to develop and this client is only 10 minutes postdelivery. 4. Although the client is at high risk for pain, especially from the episiotomy, this is not the highest priority nursing diagnosis. TEST-TAKING TIP: If the test taker remembers the ABCs—airway, breathing, circulation—he or she would realize that although the client may be in pain, that is not the priority nursing diagnosis. The client's fluid volume—that is, circulation—must take precedence.

29. A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery while the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for? 1. Pruritus. 2. Nausea. 3. Postural headache. 4. Respiratory depression.

1. Both the spinal anesthesia and the epidural anesthesia client are at high risk for developing pruritus. 2. Both the spinal anesthesia and the epidural anesthesia client are at high risk for developing nausea. 3. The client who has had the spinal anesthesia is much more likely to develop a postural headache than a client who had epidural anesthesia. 4. Both the spinal anesthesia and the epidural anesthesia client are at high risk for developing respiratory depression. TEST-TAKING TIP: Both spinal anesthesia and epidural anesthesia are forms of regional anesthesia. The same medication is used and it is placed at the same vertebral level in both instances. Only spinal anesthesia is administered into the spinal space leaving a wound through which spinal fluid can escape. When spinal fluid is lost from the spinal canal, clients are at high risk for developing postural headaches, also called spinal headaches, because of the change in pressure in the spinal canal.

43. A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication? 1. Chamomile tea can potentiate the affect of the drug. 2. Therapeutic effect may be delayed a week or more. 3. The medication should only be taken whole. 4. A weight gain of up to ten pounds is commonly seen.

1. Chamomile tea has not been shown to potentiate the affect of Zoloft, but St. John's wart has. 2. The therapeutic effect of selective serotonin receptor inhibitors (SSRIs) like Zoloft is delayed about 1 to 2 weeks from the time the medication is initiated. 3. This response is incorrect. The medication can be crushed. 4. A 10-lb weight gain is not associated with the medication. TEST-TAKING TIP: Clients, who receive medications for emotional problems as well as for physiological complaints, expect to experience resolution of their symptoms in a timely fashion. If postpartum depression clients are not forewarned of the delay of the therapeutic effects, they may stop taking the medications prematurely, believing that the medicines are useless.

79. A woman is receiving Paxil (paroxetine) for postpartum depression. In order to prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following? 1. Alcohol. 2. Grapefruit. 3. Milk. 4. Cabbage.

1. Clients should be warned about consuming alcohol when taking Paxil. 2. Grapefruit is not contraindicated for clients who have been prescribed Paxil. 3. Milk is not contraindicated for clients who have been prescribed Paxil. 4. Cabbage is not contraindicated for clients who have been prescribed Paxil. TEST-TAKING TIP: Paxil is an antidepressant. Although the concurrent use of alcohol and Paxil has not been shown to adversely affect clients' abilities, it is advised that alcohol not be consumed while taking the medication. Some clients have actually reported that they experienced a craving for alcohol while taking the medication.

24. A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

1. Foul-smelling lochia is a sign of endometritis. 2. The nurse can assist the client with actions to relieve breast engorgement. 3. The nurse can assist the client with actions to relieve cracked nipples. 4. The nurse can assist the client with actions to relieve hemorrhoid pain. TEST-TAKING TIP: Some nursing actions are dependent functions. For example, nurses are only able to administer antibiotics after receiving a physician's order. Other actions, however, are independent actions. For example, assisting a client with engorged breasts to self-express breast milk, to apply warm soaks to the breasts, and to breastfeed effectively are independent actions. The nurse must report foul-smelling lochia to the physician so that the doctor can decide whether or not to order antibiotics for the client.

74. A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following should be included in the patient teaching? 1. Only take ibuprofen for pain. 2. Avoid eating dark green leafy vegetables. 3. Drink grapefruit juice daily. 4. Report any decrease in urinary output.

1. Ibuprofen is an NSAID. It can exacerbate the action of Coumadin. The client should be encouraged to take acetaminophen, if needed, for pain. 2. This action is correct. Dark green leafy vegetables contain vitamin K. The vitamin would decrease the anticoagulant affect of Coumadin. 3. The client should be advised to avoid drinking grapefruit juice. It may increase the action of Coumadin. 4. The client should be advised to report signs of internal bleeding, such as hematuria. Decreased urinary output would not be expected in a client taking Coumadin. TEST-TAKING TIP: Patient education is essential when clients are discharged on powerful medications like Coumadin. The nurse must consider all aspects of the client's daily life, including diet (see above regarding dark green leafy vegetables); herbs taken (some, such as ginkgo biloba, and ginger, can increase the action of the medication); activities (clients should, e.g., avoid playing contact sports, using razors); and the like.

57. A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6ºF, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority? 1. Ineffective breastfeeding. 2. Infection. 3. Ineffective individual coping. 4. Pain.

1. Infection, not ineffective breastfeeding, is the priority nursing diagnosis. 2. Infection is the priority nursing diagnosis. A temperature of 104.6ºF, as well as the client's other signs/ symptoms, should immediately suggest the presence of infection. 3. Infection, not ineffective individual coping, is the priority nursing diagnosis. 4. Infection, not pain, is the priority nursing diagnosis. TEST-TAKING TIP: This client has a breast abscess. Although all of the nursing diagnoses are important, the most important diagnosis is infection. It is the only one of the four diagnoses that is related to the acute problem. Ineffective breastfeeding contributed to the development of the infection. And because of the infection, the client is in pain and is coping poorly. Once the abscess is drained and the antibiotics have been administered, the other three diagnoses will be on the road to being resolved.

63. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client? 1. The woman should never be left alone with her infant. 2. Symptoms rarely last more than one week. 3. Clinical response to medications is usually poor. 4. The woman must have her vitals assessed every two days.

1. It is essential that the client never be left alone with her baby. 2. The statement is untrue. There is no set time frame for the resolution of the symptoms of postpartum psychosis. 3. Clinical response to medications is usually quite good. 4. The client's vital signs need not be assessed frequently. TEST-TAKING TIP: Clients who have been diagnosed with postpartum psychosis have been known to have homicidal and suicidal ideations. Because the baby and other children are vulnerable, the mother should always be supervised when in their presence. In addition, if she exhibits suicidal behaviors, she should be supervised at all times.

72. A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding? 1. Have the woman wean the baby to formula. 2. Have the baby stay in the hospital room with the mother. 3. Have the woman pump and dump her milk for two weeks. 4. Have the baby bottlefed milk that the mother has stored.

1. It is unnecessary to wean the baby to formula. 2. Optimally, the baby should stay in the hospital room with the mother. 3. It is unnecessary for the mother to pump and dump for 2 weeks. 4. Although the baby could drink milk stored by the mother, this is not the best solution. TEST-TAKING TIP: Other than the period of time that the mother is in the surgical suite, there is unlikely to be anything that would warrant separating the mother from her baby. The surgeon and anesthesiologist should be able to prescribe medicines that are compatible with breastfeeding. Plus, the client could easily feed her baby while lying in a comfortable position. The client should be admitted to a hospital room that would be safe for a 6-week-old baby.

64. A postoperative cesarean client, who was diagnosed with severe preeclampsia in labor and delivery, is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question? 1. Methergine (methylergonovine). 2. Magnesium sulfate. 3. Advil (ibuprofen). 4. Morphine sulfate.

1. Methergine is contraindicated for this client. 2. Magnesium sulfate is the drug of choice for the treatment of severe preeclampsia. 3. Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID). It is an appropriate medication for the treatment of postpartum cramping. It is not contraindicated for this client. 4. Morphine sulfate is a narcotic analgesic. It is an appropriate medication for the treatment of postsurgical pain. It is not contraindicated for this client. TEST-TAKING TIP: Methergine is an oxytocic agent. It acts directly on the myofibrils of the uterus. Secondarily, it also contracts the muscles of the vascular tree. As a result, clients' blood pressures tend to elevate when they receive this medication. Methergine should not be administered to a client whose blood pressure is 130/90 or higher.

53. A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? 1. G1P0000, delivery at 29 weeks' gestation. 2. G2P1001, prolonged first stage of labor. 3. G2P0010, delivery by cesarean section. 4. G3P0200, delivery of 2200-gram neonate.

1. Preterm labor clients are not especially at high risk for postpartum hemorrhage. 2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH). 3. Cesarean section clients are not especially at high risk for PPH. 4. Clients who deliver small babies are not especially at high risk for PPH. TEST-TAKING TIP: The muscles of the uterus of a client who has experienced a prolonged first stage of labor are fatigued. In the postpartum period, therefore, they may fail to contract fully enough to control bleeding at the site of placental separation. These clients must be monitored carefully for postpartum hemorrhage.

10. The nurse should suspect puerperal infection when a client exhibits which of the following? 1. Temperature of 100.2ºF. 2. White blood cell count of 14,500 cells/mm3 . 3. Diaphoresis during the night. 4. Malodorous lochial discharge.

1. Puerperal infection is defined as a temperature of 100.4˚F or higher after 24 hours' postpartum. 2. Although clients who develop endometritis will have significantly elevated white cell counts, a WBC count of 14,500 is normal for a postpartum client. 3. Clients who develop infections may perspire profusely. However, diaphoresis is normally seen in postpartum clients, and is not in itself indicative of postpartum infection. 4. A malodorous lochial flow is a common sign of a puerperal infection. TEST-TAKING TIP: Puerperium is another word for postpartum. Although a client may have a slight temperature elevation, an elevated white cell count, and/or be diaphoretic, all three symptoms are normally seen in the postpartum client. The only finding that would make a nurse suspect infection is the malodorous lochial flow. The other findings are well within normal for a postpartum woman.

42. A client who received a spinal for her cesarean delivery is complaining of pruritus and has a macular rash on her face and arms. Which of the following medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Zofran (ondansetron). 3. Compazine (prochlorperazine). 4. Benadryl (diphenydramine).

1. Reglan is an antiemetic. It is not the appropriate medication for this client. 2. Zofran is an antiemetic. It is not the appropriate medication for this client. 3. Compazine is an antiemetic. It is not the appropriate medication for this client. 4. Benadryl is an antihistamine. It is the drug of choice for this client who has pruritus and a rash. TEST-TAKING TIP: To answer this question, the test taker must first determine what the client's clinical problem is and then determine which medication will relieve that problem. The test taker, therefore, must be familiar with the actions of major medications. The client is exhibiting signs of an allergic response. Benadryl is the only choice that will inhibit the client's immune response.

61. A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following PRN medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Demerol (meperidine). 3. Seconal (secobarbital). 4. Benadryl (diphenhydramine).

1. Reglan is an antiemetic. It is the drug of choice for a client who is vomiting after surgery. 2. Demerol is a narcotic analgesic. It is not the appropriate medication for this client. 3. Seconal is a sedative. It is not the appropriate medication for this client. 4. Benadryl is an antihistamine. It is not the appropriate medication for this client. TEST-TAKING TIP: This client is exhibiting a common side effect of regional anesthesia: nausea and vomiting. Antiemetics are the medications of choice for this problem. Many PRN medications are ordered for postsurgical clients. The test taker must become familiar with the actions and the uses of each of them.

7. A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? 1. Place the client flat in bed. 2. Assess for dependent edema. 3. Auscultate lung fields. 4. Check patellar reflexes

1. The client should not be placed flat in bed. Her bed should be placed in the Sims position to enable her to aerate well. 2. There is nothing in the scenario that suggests that this client is high risk for dependent edema. 3. It is important for the nurse to auscultate the client's lung fields every 4 hours to assess for rales. 4. There is nothing in the scenario that suggests that this client is high risk for an alteration in reflex response. TEST-TAKING TIP: A cesarean section client is a postoperative client as well as a postpartum client. The nurse must perform needed physiological assessments. Because this client had general anesthesia during her surgery, she is high risk for pulmonary complications, including atelectasis and pneumonia.

65. A nurse administered RhoGAM to a client whose blood type is A (positive). Which of the following responses would the nurse expect to see? 1. Fever, flank pain, elevated bilirubin. 2. Induration and redness at the injection site. 3. Mild pain and swelling at the injection site. 4. Polycythemia, headache, hives.

1. The nurse would expect to see fever, flank pain, and elevated bilirubin levels. 2. If the client were Rh (negative), the nurse would expect to see induration and redness at the injection site. 3. If the client were Rh (negative), the nurse would expect to see mild pain and swelling at the injection site. 4. The nurse would expect to see a hemolytic response, not polycythemia. TEST-TAKING TIP: When RhoGAM is administered to an Rh (positive) client, antibodies against the client's red blood cells are being injected into her body. A hemolytic response similar to one seen when a client receives the wrong type of blood will develop.

5. The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? 1. Massage the uterus. 2. Notify the obstetrician. 3. Administer an oxytocic as ordered. 4. Assist the client to the bathroom.

1. The uterus is contracted. Massaging the uterus will not remedy the problem of heavy lochial flow. 2. It is important for the nurse to notify the physician. The client is bleeding more than she should after the delivery. 3. An oxytocic promotes contraction of the uterine muscle. The muscle is already contracted. 4. The uterus is at the umbilicus. It is unlikely that it is displaced from a full bladder. TEST-TAKING TIP: The nurse must act as a detective to determine why he or she is seeing symptoms. In this scenario, the uterus is contracted and at the expected location—that is, firm at the umbilicus. The lochia flow, however, is heavy. The nurse must notify the practitioner for assistance since there is no additional action the nurse can take at this time.

78. On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client? 1. "Have you ever had anesthesia before?" 2. "Do you have any allergies?" 3. "Do you scar easily?" 4. "Are there many stairs in your home?"

1. This is an important question to ask the client but it is unrelated to her discharge needs. 2. This is an important question to ask the client but it is unrelated to her discharge needs. 3. This is an important question to ask the client but it is unrelated to her discharge needs. 4. The client has had major surgery. The client will need some assistance when she returns home, especially if she has a number of stairs to climb. TEST-TAKING TIP: Discharge care must begin on admission to the hospital. Cesarean section clients will need some assistance after discharge, especially if they must climb up and down stairs.

28. A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time.

1. This blood pressure shows that no adverse side effects have resulted from the administration of the medication. One side effect of the medication is an elevation in blood pressure. 2. Pulse rate is unrelated to the administration of the medication. 3. The fundal response indicates that the medication was effective in contracting the uterus. 4. The prothrombin time is unrelated to the administration of the medication. TEST-TAKING TIP: Methergine is an oxytocic agent. It is administered after delivery if the uterus is atonic or if the client is high risk for uterine atony. When the uterus is noted to be well contracted and at the appropriate position in the abdomen, the nurse can conclude that the medication action was successful.

49. A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action? 1. Postpartum hemorrhage. 2. Severe postural headache. 3. Pruritic skin rash. 4. Paralytic ileus.

1. This client in high-Fowler's position is no more at high risk for postpartum hemorrhage than a spinal anesthesia client who has been kept flat after surgery. 2. The nurse would expect the client to complain of a severe postural headache. 3. This client is no more at high risk for a pruritic rash than a spinal anesthesia client who has been kept flat after surgery 4. This client is no more at high risk for paralytic ileus than a spinal anesthesia client who has been kept flat after surgery. TEST-TAKING TIP: Postpartum hemorrhage, pruritic rash, and paralytic ileus are complications seen in post-cesarean clients, whether they received general anesthesia, epidural anesthesia, or spinal anesthesia. Only spinal clients, most notably those who elevate soon after surgery, are at high risk for postural headaches.

48. Which of the following comments suggest that a client, whose baby was born with a congenital defect, is in the bargaining phase of grief? 1. "I hate myself. I caused my baby to be sick." 2. "I'll take him to a specialist. Then he will get better." 3. "I can't seem to stop crying." 4. "This can't be happening."

1. This client is voicing anger at herself. 2. This client is exhibiting the bargaining stage of grief. 3. This client is exhibiting signs of depression. 4. This client is exhibiting denial. TEST-TAKING TIP: Although clients do not go through the stages of grief linearly, they do express the many stages of grief while they mourn the loss of their child of fantasy. Bargaining is a particularly vulnerable time for parents. Unscrupulous practitioners can make a great deal of money off couples who believe that their child can be cured from "special medicines" or "procedures."

66. A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time? 1. Tell the father that his behavior is inappropriate. 2. Sit with the family and quietly communicate sorrow at their loss. 3. Help the couple to understand that their daughter is acting inappropriately. 4. Encourage the couple to send their daughter to her grandparents.

1. This father is grieving. His anger is appropriate at this time. 2. This action is appropriate. The nurse is acknowledging that every member of the family is grieving the loss. 3. Five-year-old children do not understand death. They do respond to their parents' unusual behaviors. 4. Even though it is very difficult for the parents to deal with their own grief while caring for their daughter, the young girl may feel abandoned if sent unexpectedly to her grandparents. TEST-TAKING TIP: Each member of a family will grieve differently. One of the important actions for the nurse is to help the members of the family to communicate with one another. Children do not understand the finality of death until about age 9.

76. Which of the following is a priority nursing diagnosis for a woman, G10P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration is comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role.

1. This is an important nursing diagnosis, but it is not the priority diagnosis. 2. This is an important nursing diagnosis, but it is not the priority diagnosis. 3. Fluid volume deficit related to blood loss is the priority nursing diagnosis. 4. This is an important nursing diagnosis, but it is not the priority diagnosis. TEST-TAKING TIP: It is likely that most clients will have multiple nursing diagnoses. The nurse must then determine which is (are) the priority diagnosis(ses). It is essential that the nurse remember Maslow's Hierarchy of Needs. Although psychosocial needs are very important, the physiological needs, especially those related to the respiratory and the cardiovascular systems, must take precedence

14. A breastfeeding woman calls the pediatric nurse with the following complaint: "I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I give the baby until I get better?" Which of the following replies by the nurse is appropriate at this time? 1. "Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes." 2. "Don't forget to pump your breasts every 3 hours while you are feeding the baby the prescribed formula." 3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." 4. "In addition to feeding the baby formula, you should wear a surgical face mask when you are around him."

1. This response is inappropriate. The client should not be advised to switch to formula. 2. This response is inappropriate. The client should not be advised to switch to formula. 3. This response by the nurse is appropriate. 4. This response is inappropriate. The client should not be advised to switch to formula. TEST-TAKING TIP: First, the baby has already been exposed to the mother and will continue being exposed to her even if she switches to formula. More important, however, is the fact that the mother will produce antibodies that will be consumed by the baby in the breast milk. The baby will, therefore, be more protected by continuing to breastfeed since formula contains no protective properties.

82. A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 1. Breast implants often contaminate the milk with toxins. 2. The glandular tissue of women who need implants is often deficient. 3. Babies often have difficulty latching to the nipples of women with breast implants. 4. Women who have implants are often able exclusively to breastfeed.

1. This response is incorrect. The implants usually do not leach toxins into the surrounding tissue. 2. The glandular tissue of most women who choose to have breast augmentation surgery is normal. 3. This information is incorrect. Implants usually do not affect a baby's ability to latch. 4. This information is true. Women who have had augmentation surgery usually are able to breastfeed exclusively. TEST-TAKING TIP: Because breast implants are usually inserted behind the breast tissue, the mammary ducts are rarely affected. Daily weights of babies whose mothers have had breast enlargements should be monitored as a precaution, but most of these mothers do produce sufficient quantities of breast milk

4. A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is, "Bleeding and saturating a pad about every 1 ⁄2 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bed rest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please come in whenever you are ready."

1. This response is not appropriate. It is unlikely that this client is menstruating at 2 weeks postpartum. 2. This response is not appropriate. This client needs to be evaluated. 3. This response is not appropriate. This is an unlikely explanation for the bleeding. 4. This is the correct response. This client needs to be evaluated. TEST-TAKING TIP: The quantity of lochia discharge is usually described as scant, moderate, or heavy. A heavy discharge is described as a discharge that saturates a pad in 1 hour or less. Since this client's lochia has already changed to alba (whitish), it is especially concerning that she is now experiencing a heavy lochia rubra (reddish) flow.