Med Surg II

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs?

Retained placental fragments from delivery

The postpartum unit nurse has provided information on performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that it will promote which action?

Assist in healing and provide comfort.

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction?

"I need to isolate the infant for 48 hours after beginning the antibiotics."

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider (HCP), what is the nurse's nextaction?

Prepare the client for surgery.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids.

The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching?

"A fever on and off is expected and is nothing to worry about."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?

"What can I do for you?"

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F (37.8°C). What is the priority nursing action?

Increase hydration by encouraging oral fluids.

Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside?

Blood pressure cuff

The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action?

Massage the uterus until firm.

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Notify the health care provider (HCP).

Which additional daily dietary intake will mostclosely match the number of additional calories needed by the breast-feeding mother?

Peanut butter and jelly sandwich and glass of 2% milk

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor?

Postpartum infection

The rubella vaccine is prescribed to be administered to a client 2 days after delivery of her child. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation?

Pregnancy for 2 to 3 months after the vaccination

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client?

Maternal overexertion

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates a need for further teaching?

"I need to stop breast-feeding until this condition resolves."

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instruction?

"I need to stop breast-feeding until this condition resolves."

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client?

"You should not become pregnant for 2 to 3 months after administration of the vaccine."

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn."

The clinic nurse is performing an assessment on a client who is 6 days postpartum. When assessing involution, the nurse expects the uterine fundus to be located at which area? Click on the image to indicate your answer.

3

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression?

The mother constantly complains of tiredness and fatigue.

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant?

The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction?

The mother requests that the nurse feed the newborn because she is feeling fatigued.

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis?

Ask the client about pain in the calf area.

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?

Ask the client to urinate and empty her bladder.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take?

Assess for hypovolemia and notify the health care provider (HCP).

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time?

Concern about the loss of the baby and personal health

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate?

Cover the client with a warm blanket.

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?

Prepare an ice pack for application to the area.

The nurse caring for a client with a diagnosis of subinvolution should recognize which conditions as causes of this diagnosis? Select all that apply.

Uterine infection Retained placental fragments from delivery

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed.

The nurse is monitoring the client for signs of postpartum depression. Which behavior indicates the need for further assessment related to this form of depression?

The client constantly complains of tiredness and fatigue.

A postpartum client is diagnosed with a urinary tract infection. Which measures should the nurse instruct the client to take regarding treatment and the prevention of a future infection? Select all that apply.

Urinate frequently throughout the day. 2.Increase fluid intake to at least 3000 mL/day. Wipe the perineal area from front to back after urinating. 5.Consume foods and fluids that will increase urine acidity.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action?

Gently massage the uterine fundus.

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother on measures to take for treatment of the infection. Which statement, if made by the mother, would indicate a need for further instruction?

"Foods and fluids that will increase urine alkalinity should be consumed."

A woman infected with the human immunodeficiency virus (HIV) has given birth to an infant who appears normal, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates an understanding of the instructions? Select all that apply.`

"I am going to need to bottle-feed my baby." 2."I need to wash my hands before and after bathroom use." 3."I can transmit the infection to my baby when I breast-feed." "I am going to contact some support groups to help me cope and learn ways to deal with things when I get home."

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statements by the client indicate the need for further instruction? Select all that apply.

"I need to breast-feed, especially for the first 6 weeks postpartum." "My baby has no symptoms so it is not likely that he has gotten the infection from me."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?

"I should wash my nipples daily with soap and water."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions?

"If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider."

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. How often should the nurse plan to take the client's vital signs?

15 minutes during the first hour and then every 30 minutes for the next 2 hours

A postpartum unit nurse is caring for a stable client 12 hours after delivering a healthy newborn. At this time in the postpartum period, what is the recommended frequency for the nurse to assess the client's vital signs?

Every 4 hours

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?

Massage the fundus until it is firm.

Which instructions should the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply.

Report a foul-smelling discharge. 2.Take a warm sitz baths 3 times a day. Use warm water to rinse the perineum after elimination. 5.Wipe the perineum from front to back after voiding and defecation.

The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation?

The client is experiencing normal lochia discharge.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which clients would be at mostrisk for development of postpartum thromboembolic disorders? Select all that apply.

A 39-year-old woman who reports that she smokes A 37-year-old woman in her fourth pregnancy who is overweight 5.A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

The nurse is caring for a client who has just delivered a newborn following a pregnancy with placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa?

Hemorrhage

A postpartum care unit nurse is reviewing the records of 5 new mothers admitted to the unit. The nurse determines that which mother is most likely at risk for developing a puerperal infection? Select all that apply.

A mother who had 10 vaginal exams during labor 2.A mother with a history of previous puerperal infections A mother who experienced prolonged rupture of the membranes

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response?

"Mastitis can occur at any time during breast-feeding."

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructionswhen the client makes which statement?

"The only medications I will take are prenatal vitamins and stool softeners."

The postpartum unit nurse is creating a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan?

Encourage the mother to hold the infant when the infant cries.

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?

Encouraging fluid intake

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?

"Foods and fluids that will increase urine alkalinity should be consumed."

The nurse is monitoring a postpartum client who is at risk for developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, supports a diagnosis of postpartum endometritis?

Abdominal tenderness and chills

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal?

The saturation of more than 1 peripad per hour

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education?

"I should apply my antiembolism stockings after breakfast."

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.

"I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method?

"I should weigh the perineal pad before and after use and note the amount of time between each pad change."

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction?

"If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately."

The nursing instructor is reviewing the plan of care for a postpartum client with a student. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which responses made by the student indicate an understanding of this phase? Select all that apply.

"The client may complain of lack of sleep and fatigue." 5."The client is self-focused and talks to others about labor."

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and also notes that this is the client's first child. Which nursing interventions are most appropriate in assisting the promotion of mother-infant interaction and bonding? Select all that apply.

Accepting the client's feelings 2.Acknowledging the client's apprehension 3.Assisting the client with giving the baths to allow her to become more at ease

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day?

500

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin induction

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis?

Ambulate frequently.

The nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis?

An adolescent experiencing an emergency cesarean delivery for fetal distress

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats/minute

The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which indicates an early sign of excessive blood loss?

An increased pulse rate of 88 to 102 beats/min

When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis?

Massage distended areas as the infant nurses.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure?

Breast-feed from the left breast and gently pump the right breast.

The nurse is creating a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed?

Elevation of the affected extremity

Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care?

Encourage the client to take pain medication as prescribed.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action?

Palpating the uterine fundus

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.

Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs.

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant.

The nurse is caring for four 1-day postpartum clients. Which client assessment requires theneed for follow-up?

The client with lochia that is red and has a foul-smelling odor

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

At 10 days postpartum, a breast-feeding mother develops mastitis in her right breast. The nurse plans to instruct the client on which interventions? Select all that apply.

Using ice packs 2.Using analgesics Wearing proper breast support 5.Completing the full course of prescribed antibiotics.

The nurse visits at home a client who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply.

Wear a supportive bra between feedings. 2. Apply moist heat to both breasts for about 20 minutes before a feeding. 3. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. Massage the breasts gently during a feeding, from the outer areas to the nipples.

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

The rubella vaccine has been prescribed for a new mother. Which statements should the postpartum nurse make when providing information about the vaccine to the client? Select all that apply.

"You need this vaccine because you are not immune to the rubella virus." "You should not become pregnant for 1 to 3 months after the administration of the vaccine."

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity?

Breast-feeding

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

Massage the fundus until it is firm.

The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply.

Massaging the uterus Assisting the woman to urinate Checking for a distended bladder

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant?

Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp.

The client delivered a newborn baby 3 hours ago. The assigned nurse is reviewing the electronic health record to determine if the new mother is a candidate for Rh immune globulin administration. Which criteria must be present in order to administer this medication correctly? Select all that apply.

The mother must be Rh negative. 3.The newborn must be Rh positive. 4.The indirect Coombs' test must be negative.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

Wear a supportive bra. 2.Rest during the acute phase. 3.Maintain a fluid intake of at least 3000 mL/day. 4.Continue to breast-feed if the breasts are not too sore.

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client?

Wear a supportive brassiere continuously for 72 hours.