NCLEX ch 25 The Postpartum Period and Associated Complications

Massage the breasts before feeding to stimulate let-down.

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement? 1. Breastfeed only during the daytime hours. 2. Apply cold compresses to the breast before feeding. 3. Avoid the use of a bra while the breasts are engorged. 4. Massage the breasts before feeding to stimulate let-down.

"I don't need birth control because I will be breastfeeding."

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? 1. "I don't need birth control because I will be breastfeeding." 2. "I need to increase my caloric intake by 500 calories a day." 3. "I shouldn't use soap to wash my breasts because I will be breastfeeding." 4. "I need to be sure that I increase my fluid intake and take my prenatal vitamins while breastfeeding."

At the level of the umbilicus

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note? 1. To the right of the abdomen 2. At the level of the umbilicus 3. About 4 cm above the level of the umbilicus 4. One fingerbreadth above the symphysis pubis

The bright red bleeding is abnormal and should be reported.

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make? 1. This is a normal expectation after episiotomy. 2. The mother should be allowed bathroom privileges only. 3. The bright red bleeding is abnormal and should be reported. 4. The perineal assessment should be performed more frequently.

Prepare the client for surgery

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action? 1. Reassure the client 2. Apply perineal pressure 3. Monitor fundal height 4. Prepare the client for surgery

Ambulate frequently.

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action? 1. Ambulate frequently. 2. Wear support stockings. 3. Apply warm, moist packs to the legs. 4. Remain on bed rest, with the legs elevated.

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? 1. The inverted uterus returning to normal 2. The gradual reversal of the uterine muscle into the abdominal cavity 3. The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

Keep the client and her family members informed of her progress

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action? 1. Maintain strict bed rest 2. Monitor the vital signs every 2 hours 3. Perform firm fundal massage every 2 hours 4. Keep the client and her family members informed of her progress

Prepare an ice pack for application to the area.

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action? 1. Check vital signs every 4 hours. 2. Measure the fundal height every 4 hours. 3. Prepare a heat pack for application to the area. 4. Prepare an ice pack for application to the area.

Vital signs

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? 1. Vital signs 2. Fundal height 3. Presence of calf pain 4. Level of consciousness (LOC)

Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action? 1. Apply cool packs to the abdomen. 2. Continue to monitor the temperature. 3. Remove the blanket from the client's bed. 4. Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).

1. Rest during the acute phase. 2. Wear a supportive, nonunderwire bra. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breastfeed if the breasts are not too sore.

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Rest during the acute phase. 2. Wear a supportive, nonunderwire bra. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breastfeed if the breasts are not too sore. 5. Take prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breastfeeding or breast pumping.

Checks the vital signs

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action? 1. Checks the vital signs 2. Begins fundal massage 3. Encourages ambulation 4. Encourages the client to drink fluids

Red

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note? 1. Red 2. Pink 3. White 4. Serosanguineous

Administer oxygen by face mask, as prescribed.

The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? 1. Monitor the vital signs. 2. Elevate the head of the bed. 3. Increase the intravenous flow rate. 4. Administer oxygen by face mask, as prescribed.