NCLEX Postpartum
The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals?
Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours
When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which nursing action is appropriate?
Notify the registered nurse (RN).
The nurse is caring for a woman who has delivered a baby after a pregnancy with a placenta previa. Which complication would the client be at risk for?
Postpartum hemorrhage
A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence?
Retained placental fragments and infections
The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching?
"I will change the perineum pads three times a day."
The nurse provides instructions to a breast-feeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures?
"I will massage the breasts before feeding to stimulate let-down."
The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration?
"It will help prevent and control bleeding if it occurs."
A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, holding and touching the baby. Which statement by the nurse should further assist the family in their initial period of grief?
"Would you like to hold your baby?"
The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse instruct
500 calories per day
A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client?
Begin feeding on the less sore nipple.
A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should take which approach as the first step to support the client psychologically?
Collect data regarding how the client perceived the event.
A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago. The mother's temperature is 100° F (38° C). What is the initial nursing action?
Encourage oral fluid intake
The nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action is appropriate?
Encourage oral fluids.
The nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the client's participation in infant care?
Encouraging the client to take pain medication as prescribed
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?
Keeping the client and her family members informed of her progress
A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which?
Less pain
The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions would be included in the plan of care? Select all that apply.
Maintaining bed rest Elevating the affected extremity Applying warm compresses to the affected area as prescribed
The nurse is assigned to care for a client in the immediate postpartum period who received methylergonovine maleate. The nurse determines the medication is effective when the client makes which statement?
My afterpains are really strong
The nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?
Postpartum hemorrhage
A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?
Prepare to administer oxygen at 8 to 10 L by tight face mask.
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. On the basis of this diagnosis, the nurse should plan which action?
Preparing the client for surgery
A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response?
Request to hold the infant following delivery
The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which?
The presence of infection
The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation?
The spouse lacks hope because of the loss of the baby and illness of his wife.
The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client?
To complete the entire antibiotic regimen
The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which problem is most likely to occur during this stage?
Urinary retention caused by the loss of sensation to void and rapid bladder filling
It has been 12 hours since a client's delivery of a newborn. The nurse assesses the mother for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? Refer to figure
1
Which safety measures that should be implemented when working in the newborn nursery? Select all that apply.
Adhere to standard precautions. The parents should be instructed to not release their infant to anyone wearing improper identification. The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room.
The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first?
Assist the client to the bathroom to void and then reassess the fundus.
A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note which uterine fundus position?
At the level of the umbilicus
The nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed which amount?
Eight pads a day
In formulating the plan of care, which problem is most important to address for a postpartum client who has expressed concerns about not knowing how to care for her newborn?
Lack of knowledge regarding ability to care for the newborn
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?
Notify the registered nurse, who will then contact the health care provider (HCP).
The nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs?
Checks the calf areas for redness or swelling
The parents of a neonate who is not circumcised request information on how to clean the newborn's penis. Which is the correct response for the nurse to make to the parents?
"Avoid retracting the foreskin to cleanse the glans because this may cause adhesions."
A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breast-feed the baby as planned after delivery. The nurse makes which response to the client?
"Breast-feeding is allowed once the baby has been vaccinated."
The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching?
"I can start doing abdominal exercises as soon as I get home."
The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a further teaching
"I should avoid wearing a bra at this time."
The nurse is reinforcing instructions to a client who had an episiotomy during the birthing process. Which statement by the client would indicate a need for further teaching?
"I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115° F."
The nurse reinforces home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?
"If I develop a fever, I will call my doctor."
A postpartum client who delivered at 32 weeks of gestation would like to breast-feed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?
"You can begin pumping as soon as possible after delivery with an electric breast pump."
A postpartum client with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse should make which response to the client?
"You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus."
The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action?
Administer anticoagulants as prescribed.
The nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery?
An adolescent experiencing an emergency cesarean delivery for fetal distress
The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is important for the nurse to take at this time?
Check the uterine fundus and lochia.
The nurse is reviewing the procedure for vitamin K injection in a newborn. Which information is included in the procedure?
Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute.
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.
Rest during the acute phase. Wear a supportive, nonunderwire bra. Maintain a fluid intake of at least 3000 mL. Continue to breastfeed if the breasts are not too sore.
After a precipitate delivery, the nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which action first to help the woman process what has happened?
Support the mother no matter what her reaction is to the newborn
The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding should indicate which accurate interpretation to the nurse?
This may be a sign of hemorrhage or shock.
The nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery would support this diagnosis?
Abdominal tenderness and
