OB QUIZ 2

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate?

"It might take up to a week for your bowels return to their normal pattern."

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?

Tachycardia and a falling blood pressure

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.

The client may spend the latent phase of the first stage of labor at home unless which occurs?

The client experiences a rupture of membranes

During labor, a pregnant patient's doula uses therapeutic touch and massage. Which outcome indicates that these approaches have been effective?

The patient is not requesting pain medication.

Which assessment finding is most important as labor progresses?

The uterus relaxes completely between contractions.

The pain of labor is influenced by many factors. What is one of these factors?

The woman is prepared for labor and birth.

The nurse instructs the client about skin massage and the gate-control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods?

This is a technique to prevent the painful stimuli from entering the brain.

The laboring client who is at 3 cm dilation and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?

This may prolong labor and increase complications.

Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition?

Thromboembolism

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition?

Urinary tract infection

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

Venous duplex ultrasound of the right leg

At what time is the laboring client encouraged to push?

When the cervix is fully dilated

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which phase of the contraction?

acme

A client has asked that an opioid be kept on standby in case she needs it for pain control. As a precaution, the nurse will also have which of medication readily available to reverse the effects of that opioid?

naloxone

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior?

negative attachment

During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention?

peribottle and warm water

A nurse is conducting a in-service education program for a group of nurses working in the postpartum unit about postpartal infection. The nurse determines that the teaching was successful when the group identifies which factor as contributing to the risk for infection postpartally?

placenta removed via manual extraction

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?

policies that discourage unwrapping and exploring the infant

The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse watch in the client? Select all that apply.

- incomplete emptying of bladder - bladder distention -urinary retention

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply.

-Fundus one fingerbreadth below the umbilicus -Moderate saturation of peripad every 3 hours

Parents tell the nurse that their 3-year-old son has begun to have "accidents" at home following the arrival of his baby sister and wants to sit in his mother's lap all the time now. What advice would the nurse offer these parents? Select all that apply.

-Set aside time every day for the parents to focus on the big brother exclusively. -Buy the older sibling a doll for him to care for, as the mother is caring for the new baby. -Be aware of potential aggressive behaviors from the older sibling.

The nurse is concerned that a new mother is developing a postpartum complication. What did the nurse most likely assess in this patient?

Absence of lochia

The nurse is assessing a laboring client and notes: 5 cm dilated, 80% effaced, zero station, contractions every 2 to 3 minutes, lasting 50 seconds, becoming increasingly uncomfortable, and apprehensive but appropriate and focused on breathing and relaxation. The nurse determines which nursing diagnosis is most appropriate for this client?

Acute pain related to uterine contractions

Which statement is true regarding analgesia versus anesthesia?

Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area.

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?

Anxiety can slow down labor and decrease oxygen to the fetus.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

Applying ice

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad.

A postpartum client tells the nurse that she feels like crying for no apparent reason and is unable to sleep well. What should the nurse point out to the client that this may be related to?

Decreased progesterone levels

When palpating for fundal height on a postpartal woman, which technique is preferable?

Placing one hand at the base of the uterus, one on the fundus

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?

Postpartum diuresis

The nurse is preparing to administer an intradermal water injection to a client who is in labor. Which action should the nurse prioritize?

Prepare four 1 mL syringes of 0.05 to 0.1 mL sterile water using a 25 gauge needle.

Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection?

During the first 24 hours after delivery owing to dehydration from exertion

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best?

"The analgesia will reduce the sensation of pain for a limited period of time."

The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?

"The baby is coming. I'll explain what's happening and guide you."

An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification?

"The client reports a pain level of 8. She has a low pain tolerance."

A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse?

"The injection is given in the space outside the spinal cord."

The spouse of a pregnant patient is concerned about the risk of paralysis from an epidural block being used during labor. How should the nurse respond to the spouse's concern?

"The injection is given in the space outside the spinal cord."

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate?

"You might try using a water-soluble lubricant to ease the discomfort."

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.

-women on antithyroid medications -women on antineoplastic medications -women using street drugs

A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR?

10:30 a.m.

The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?

110 to 160 bpm

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval?

2 weeks

The postpartum nurse is assessing clients, all delivered within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartal blues?

30 year old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding.

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?

500 additional calories per day

During a home visit, the client mentions she is still having significant of joint pain. The nurse explains that the changes that softened the pelvic joints to allow for the birth were due to the hormone relaxin. The nurse informs the client that it takes approximately how long for the joints to return to prepregnancy status?

6 to 8 weeks after pregnancy

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

7.15 or less.

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m.

A G3 P2 with no apparent risk factors presents to the labor-and-delivery suite in early labor. She refuses the fetal monitor, stating she delivered her second baby at home without a monitor and everything went well. What is the nurse's best response?

A few minutes on the monitor will ensure the baby is doing well and then the baby can then be monitored intermittently.

A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes?

A positive Nitrazine test

A nurse notes the digital readings of the electronic fetal monitor shows decreased beat-to-beat variability in a client who was just admitted to the unit. The nurse interprets this as indicating which system is mainly being affected in the fetus?

Central nervous system

The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process?

Client priorities and preferences are incorporated into the plan.

Transcutaneous electrical nerve stimulation (TENS) reduces pain by which of the following mechanisms?

Electrical impulses are created that interfere with nerve transmission.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently.

A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response?

Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.

There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration?

It can be administered by the nurse.

The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8oF, contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?

Meconium in the fluid

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?

Moderate

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer?

On the uterine fundus

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?

Oxytocin

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do?

Palpate the mother's radial pulse at the same time.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client?

an ice pack applied to the perineum

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline FHR.

The nurse is providing preoperative care for a client who will undergo a cesarean section. The nurse should:

confirm that consent has been provided by the client.

A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:

encouraging the client to wear a supportive bra.

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client?

fever more than 100.4° F (38° C)

A young mother is at the office for her 6-week visit. She is still experiencing mild loch alba and is concerned that she has an infection. Which finding would the nurse interpret as supporting this suspicion?

foul odor

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?

hemorrhage

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?

hypovolemia

The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:

left lower quadrant.

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition?

long-term obesity

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:

maintain previous household routines to prevent infection.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?

mastitis

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?

meperidine

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:

pulmonary embolism.

Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis?

redness in lower legs

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client?

starting an IV and hanging IV fluids

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

taking-in

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in?

taking-in phase

To assess the frequency of a woman's labor contractions, the nurse would time:

the beginning of one contraction to the beginning of the next.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

• Help the mother initiate breastfeeding within 30 minutes of birth. • Encourage breastfeeding of the newborn infant on demand. • Place baby in uninterrupted skin-to-skin contact with the mother.

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply.

• vital signs of mother • pain level • head-to-toe assessment

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?

To check for postpartum hemorrhage

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

the level of the umbilicus

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?

the taking-hold phase

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?

thromboembolic disorder of the lower extremities

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?

touching

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?

prolonged decelerations

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information?

"I only eat a low-fiber diet."

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?

"You might try using a water-soluble lubricant to ease the discomfort."

A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."

During the early postpartum period, a new mother is displaying dependent behaviors. What behaviors would the nurse recognize as normal for this period? Select all that apply.

- Needing assistance with changing her peripad - Telling the nurse about her delivery experience. -Asking the nurse to take the newborn away so she can rest.

A nurse is teaching a couple about patterned breathing during their birth education. Which technique should the nurse suggest for slow-paced breathing?

Inhale slowly through nose and exhale through pursed lips.

A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilatation, she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?

Assess fetal heart rate.

The nurse is assessing a client who has just given birth and notes her prelabor vital signs reveal a temperature 98.8oF (37.1oC), blood pressure 120/70 mm Hg, HR 80, and RR 20. Which current vital sign assessment should the nurse prioritize?

Blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min.

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn?

Bringing the newborn into the room

The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?

Fear of pain during labor

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?

Feed the baby at least every two or three hours

How does a woman who feels in control of the situation during labor influence her pain?

Feelings of control are inversely related to the client's report of pain.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

Fourth degree

The nurse is caring for a client who appears tense and apprehensive as labor progresses. Which nursing intervention is most helpful?

Initiate comfort measures

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Resume intercourse if bright-red bleeding stops.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?

Showing increased confidence when caring for the newborn

A woman who is two days postpartum has painful hemorrhoids postpartally. Which of the following positions would you suggest she use for resting?

Sims' position

Which factor might result in a decreased supply of breast milk in a postpartum client?

Supplemental feedings with formula

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?

administration of oxygen by mask

A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience?

postpartum baby blues

A nursing student learns that a certain condition occurring in up to 3 in every 1,000 births is a major cause of death. What is this condition?

pulmonary embolism

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?

Difficulty breathing

A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize?

"After birth it is easier to develop an infection in the urinary system; we need to see you today."

The nurse is assisting a young mother who has decided not to breastfeed her infant. The nurse should make which suggestions to the client to ease discomfort and prevent breast engorgement? Select all that apply.

- Wear tight supportive bra 24 hours each day. - Apply ice to the breast for approximately 15 to 20 minutes every other hour. -Avoid sexual stimulation.

A pregnant patient received a narcotic analgesic 2 hours before delivery. The newborn is lethargic and difficult to arouse. What should the nurse prepare to do to help this newborn?

Administer naloxone hydrochloride.

A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?

Assess for labor progression.

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority?

Assign a female nurse to care for her.

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?

Assist the woman in placing ice packs on her breasts

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

touching

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus.

The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 gm/dL and hematocrit of 42%. Which result should the nurse prioritize?

Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?

Respiratory status

A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client?

Her bladder for distension

The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?

Inability to push

The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?

Continuous labor support

A patient in labor is prescribed transcutaneous electrical nerve stimulation (TENS) to help with pain relief during labor. How should the nurse explain the process of pain relief with this method?

Counterirritation stimulation blocks pain from traveling to the spinal cord.

The nurse is assessing the fundus of a patient on postpartum day 2. What should the nurse expect when palpating the fundus?

Fundus two fingerbreadths below umbilicus and firm

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

Hemorrhage

A woman who gave birth 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, the nurse notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this client?

Increased intake will rehydrate the patient and decrease her skin temperature.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

Percussion reveals dullness

The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients?

Thoroughly wash the hands before and after client contact.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

acutely decreased.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate

The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration?

engorgement

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase?

taking-in phase