NURS 415 FINAL

Baby-friendly hospitals mandate that infants be put to breast within the first _______ after birth.

1 hour

In response to finding excessive blood loss or other indications of PPH, what is the order of steps that you should you do?

1. FUNDAL MASSAGE 2. Expel any clots 3. Check for bladder distention 4. Notify provider for pitocin (10-40mg cont. infused in 1000ml) 5. Any additional uterine meds notify provider findings, actions taken + results

4. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman 1 day postpartum. An expected finding is: A. Little if any change. B. Leakage of milk at let-down. C. Swollen, warm and tender on palpation. D. A few blisters and a bruise on each areola.

A. Little if any change.

The breasts of a woman who is exclusively formula feeding her baby are engorged. The nurse should instruct her to: A. Wear a snug, supportive bra. B. Allow warm water to soothe the breasts during a shower. C. Express milk from breasts occasionally to relieve discomfort. D. Place absorbent pads with plastic liners into her bra to absorb leakage.

A. Wear a snug, supportive bra.

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious likely consequence of bladder distention is:. a. Urinary tract infection. B. Excessive uterine bleeding. C. A ruptured bladder. D. Bladder wall atony.

B. Excessive uterine bleeding.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum. B. Washes from symphysis pubis back to the episiotomy. C. Changes her perineal pad every 2 to 3 hours. D. Uses the peri-bottle to rinse upward into her vagina.

D. Uses the peri-bottle to rinse upward into her vagina.

A physician orders methylergonovine (Methergine) 0.2 mg IM for a postpartum client. Which intervention should the nurse take prior to administering this medication? a. Obtain the client's blood pressure (BP). b. Determine the client's blood glucose level. c. Take the client's pulse. d. Have the client empty her bladder.

a. Obtain the client's blood pressure (BP). This medication is used to stimulate the uterus to contract and prevent or treat postpartum hemorrhage due to atony or sub-involution of the uterus. A mother will go through frequent vital sign assessment (specifically monitoring BP - BP MAY RISE). Notify nurse if chest pain, SOB, seizures etc. occur

What is the priority nursing dx for the fourth stage of labor?

Risk for deficient fluid volume related to blood loss associated with birth reflects the major PP complication: PPH expected outcome: firm fundus with moderate lochial flow

Which of the following findings would raise concern for the nurse who is monitoring a postpartum patient who had a spontaneous vaginal delivery (SVD) of a 10-lb baby boy? A. Lochia rubra with minimal clots expressed on fundal massage B. Fundus midline and firm with nonpalpable bladder C. Fundus midline and firm with spurts of bright red blood upon fundal massage D. Patient report of mild to moderate cramping and request for pain medication

C. Fundus midline and firm with spurts of bright red blood upon fundal massage

Which postpartum infection is most often contracted by first-time mothers who are breastfeeding? A. Endometritis B. Wound infections C. Mastitis D. Urinary tract infections (UTIs)

C. Mastitis

With regard to afterbirth pains, nurses should be aware that these pains are: A. Caused by mild, continual contractions for the duration of the postpartum period. B. More common in first-time mothers. C. More noticeable in births in which the uterus was overdistended. D. Alleviated somewhat when the mother breastfeeds.

C. More noticeable in births in which the uterus was overdistended.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: A. Begin an IV infusion of Ringer's lactate solution. B. Assess the woman's vital signs. C. Call the woman's primary health care provider. D. Massage the woman's fundus.

D. Massage the woman's fundus.

Which finding would be a source of concern if noted during the assessment of a woman at 12 hours postpartum? A. Postural hypotension B. Temperature of 38° C (100.4 F) C. Bradycardia—pulse rate of 55 beats/min D. Pain in left calf with dorsiflexion of left foot

D. Pain in left calf with dorsiflexion of left foot

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: A. Place her on a bedpan to empty her bladder B. Massage her fundus C. Call the physician D. Administer methylergonovine (Methergine), 0.2 mg IM, which has been ordered prn

B. Massage her fundus

Excessive blood loss after childbirth can have several causes; however, the most common is: A. Vaginal or vulvar hematomas. B. Unrepaired lacerations of the vagina or cervix. C. Failure of the uterine muscle to contract firmly. D. Retained placental fragments.

C. Failure of the uterine muscle to contract firmly.