Perry Ch 19 Practice Questions
Rho immune globulin will be ordered postpartum if which situation occurs? a) Mother Rh-, baby Rh+ b) Mother Rh-, baby Rh- c) Mother Rh+, baby Rh+ d) Mother Rh+, baby Rh-
A An Rh- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated.
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? a) 3 days postpartum b) 7 days postpartum c) On the day of birth d) Within 2 weeks postpartum
A Normal bowel elimination usually returns 2-3 days postpartum.
When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is: a) Rectal suppositories b) Early and frequent ambulation c) Tightening and relaxing abdominal muscles d) Carbonated beverages
B Activity will aid the movement of accumulated gas in the gastrointestinal tract.
A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? a) Pulse b) Fundus c) Bladder d) Breast
B Because her uterus has been stretched so many times, she is at high risk for uterine atony during the postpartum period.
The nurse is developing a plan of care for the postpartum client during the "taking" in phase. Which of the following should the nurse include in the plan? a) Teach baby-care skills like diapering b) Discuss the labor and birth w/ the mother c) Discuss contraceptive choices w/ the mother d) Teach breastfeeding skills like pumping
B During the taking in phase, clients need to internalize their labor experiences.
A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? a) Take the woman's temperature b) Advise the woman to decrease her fluid intake c) Reassure the woman that this is normal d) Inform the neonate's pediatrician
C Diaphoresis is normal during the postpartum period.
The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? a) Record the findings b) Massage the fundus c) Notify the HCP d) Place the client in Trendelenburg's position
C If bleeding is excessive, the cause may be laceration of the cervix or birth canal.
The nurse monitors his/her postpartum clients carefully because of which of the following physiological changes occurs during the early postpartum period? a) Decreased urinary output b) Increased BP c) Decreased blood volume d) Increased estrogen level
C The blood volume does drop precipitously during the early postpartum period.
The nurse is caring for a client who had a C-section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? a) Elevate the head of the bed 60 degrees b) Report absence of bowel sounds to the physician c) Have her turn and deep breathe every 2 hours d) Assess for patellar hyperrflexia bilaterally
C The woman should turn, cough, and deep breathe every 2 hours.
Excessive blood loss after childbirth can have several causes; 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 Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention.
The nurse caring for the postpartum woman understands that breast engorgement is caused by: a) Overproduction of colostrum b) Accumulation of milk in the lactiferous ducts and glands c) Hyperplasia of mammary tissue d) Congestion of veins and lymphatics
D Breast engorgement is caused by the temporary congestion of veins and lymphatics.
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. What is the priority nursing action? a) Document the findings b) Retake the temperature in 15 minutes c) Notify the HCP d) Increase hydration by encouraging oral fluids
D High temperatures in the first 24hr after birth often are related to the dehydrating effects of labor.
A client in the PP unit complains of sudden sharp chest pain and dyspnea. 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? a) Initiate an IV line b) Assess the client's BP c) Prepare to administer morphine sulfate d) Administer oxygen, 8-10 L/min, by face mask
D If pulmonary embolism is suspected, oxygen should be administered, 8-10 L/min, by face mask.
Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is: a) Pouring water from a squeeze bottle over the womans perineum b) Placing oil of peppermint in a bedpan under the woman c) Asking the physician to prescribe analgesics d) Inserting a sterile catheter
D Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication).
A patient, G2P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2ºF. Which of the following is the appropriate nursing intervention at this time? a) Notify the doctor to get an order for acetaminophen b) Request an infectious disease consult from the doctor c) Provide the woman with cool compresses d) Encourage intake of water and other fluids
D It's likely that the client is dehydrated. She should be advised to drink fluids.
A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet." Which of the following responses is appropriate? a) "It's fine for you to start dieting right now as long as you drink plenty of milk." b) "Your breast milk will be low in vitamins if you start to diet while breastfeeding." c) "You must eat at least 3,000 calories per day in order to produce enough milk for your baby." d) "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."
D Many mothers who consume approximately the same number of calories while breastfeeding as they did when they were pregnancy do lost weight while breastfeeding.
The nurse is providing instructions about measures to provide PP mastitis to a client who is breast-feeding her newborn. Which client statement would indicate the need for further instruction? a) "I should breastfeed every 2-3 hours" b) "I should change the breast pads frequently" c) "I should wash my hands well before breastfeeding" d) "I should wash my nipples daily w/ soap and water"
D Soap is drying and could lead to cracking of the nipples.
A bottle-feeding woman, 1 1/2 weeks postpartum from a vaginal delivery, calls the OB office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate? a) "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." b) "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." c) "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." d) "It is important for you to be examined by the doctor today. Let me check to see when you can come in."
D The client should be examined to assess her involution.
The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6˚F, 82, 18; fundus firm at umbilicus; moderate lochia; ambulated to bathroom to void 4 times; breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? a) Fluid volume deficit r/t excess blood loss b) Impaired skin integrity r/t vaginal delivery c) Impaired urinary elimination r/t excess output d) Knowledge deficit r/t lack of parenting experiences
D This client is a primigravida. The nurse would anticipate that she is in need of teaching regarding newborn care as well as self-care.
A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. a) Increase her fluid intake for a few days b) Massage her breasts every 4 hours c) Apply heat packs to her axillae d) Wear a supportive bra 24 hours a day e) Stand w/ her back toward the shower water
D, E These are appropriate.
The nurse should warn a client who is about to receive Methergine of which of the following side effects? a) Headache b) Nausea c) Cramping d) Fatigue
C Cramping is an expected outcome of the administration of Methergine.
The nurse takes a newborn to a primipara for a feeding. The mother holds the baby enface, strokes his cheek, and states that this is the first newborn she has ever held. Which of the following nursing assessments is appropriate? a) Positive bonding and client needs little teaching b) Positive bonding but teaching related to newborn care is needed c) Poor bonding and referral to a child abuse agency is essential d) Poor bonding but there is potential for positive mothering
B The client is showing signs of positive bonding.
A nurse is assessing the fundus of a client during the immediate pospartum period. Which of the following actions indicates that the nurse is performing the skill correctly? a) The nurse measures the fundal height using a paper centimeter tape b) The nurse stabilizes the base of the uterus w/ his or her dependent hand c) The nurse palpates the fundus w/ the tips of his/her fingers d) The nurse precedes the assessment w/ a sterile vaginal exam
B The nurse should stabilize the base of the uterus w/ his or her dependent hand.
Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? a) Hct 39% b) WBC count 16,000 cells/mm3 c) RBC count 5 million cells/mm3 d) Hgb 15 g/dL
B The nurse would expect to see an elevated white count.
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? a) Encourage the woman exclusively to breastfeed her baby b) Have the woman massage her breasts hourly c) Obtain an order to culture her expressed breast milk d) Take the temperature and pulse rate of the woman
A Clients should be strongly encouraged exclusively to breastfeed their babies to prevent engorgement.
Which fo the following nursing interventions would be appropriate for the nurse to perform to achieve the client care goal: The client will not develop postpartum thrombophlebitis? a) Encourage early ambulation b) Promote oral fluid intake c) Massage the legs of the client twice daily d) Provide the client w/ high-fiber foods
A Early ambulation helps to prevent thrombophlebitis.
Which of the following is the priority nursing action during the immediate postpartum period? a) Palpate fundus b) Check pain level c) Perform pericare d) Assess breasts
A Fundal assessment is the priority nursing action.
A nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? a) Apply an ice pack to the perineum b) Advise the woman to use a sitz bath after every voiding c) Advise the woman to sit on a pillow d) Teach the woman to insert nothing into her rectum
A Ice packs hep to reduce the inflammatory response and numb the area.
During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following S&S? Select all that apply. a) Pain b) Warmth c) Discharge d) Ecchymosis e) Redness
A, B, E These are all appropriate assessments.
The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? a) Estrogen b) Prolactin c) Human placental lactogen d) Human chorionic gonadotropin
B Prolactin will elevate sharply in the client's bloodstream.
The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? a) Fundus 1 cm above the umbilicus, lochia rosa b) Fundus 2 cm above the umbilicus, lochia alba c) Fundus 2 cm above the umbilicus, lochia rubra d) Fundus 3 cm above the umbilicus, lochia serosa
D The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3.
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 intravenous (IV) infusion of Ringers 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 The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.
A nurse is assessing a 1-day postpartum woman who had her baby by cesarean section. Which fo the following should the nurse report to the surgeon? a) Fundus at the umbilicus b) Nodular breasts c) Pulse rate 60 bpm d) Pad saturation every 30 minutes
D This blood loss is excessive, especially for a postoperative cesarean section.
In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: a) Has recovered from epidural or spinal anesthesia b) Has hidden bleeding underneath her c) Has regained some flexibility d) Is a candidate to go home after 6 hours
A If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia.
In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice: a) Is inconsistent with the Baby Friendly Hospital Initiative b) Promotes longer periods of breastfeeding c) Is perceived as supportive to both bottle-feeding and breastfeeding mothers d) Is associated with earlier cessation of breastfeeding
A Infant formula should not be given to mothers who are breastfeeding.
Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? a) Lie prone w/ a small pillow cushioning her abdomen b) Contract her abdominal muscles for a count of ten c) Slowly ambulate in the hallways d) Drink ice tea w/ lemon or lime
A Lying prone on a pillow helps to relieve some women's afterbirth pains.
The nurse is planning care for a PP client who had a vaginal delivery 2 hours ago. The client requested an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? a) Client pain level b) Inadequate urinary output c) Client perception of body changes d) Potential for imbalanced body fluid volume
A Most clients have some degree of discomfort during the immediate PP period.
The nurse is preparing a list of self-care instructions for a PP client who was diagnosed w/ mastitis. Which instructions should be included on the list? Select all that apply. a) Wear a supportive bra b) Rest during the acute phase c) Maintain a fluid intake of at least 3000 mL/day d) Continue to breastfeed if the breasts are not too sore e) Take the prescribed antibiotics until the soreness subsides f) Avoid decompression of the breasts by breast-feeding or breast pump
A, B, C, D Client instructions include resting during the acute phase, maintaining fluid intake of at least 3000 mL/day, and taking analgesics to relieve discomfort. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra.
A nurse is performing a postpartum assessment on a newly delivered client. Which fo the following actions will the nurse perform? Select all that apply. a) Palpate the breasts b) Auscultate the carotid c) Check vaginal discharge d) Assess the extremities e) Inspect the perineum
A, C, D, E These are all appropriate assessments.
The nurse is monitoring a client in the immediate PP period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? a) Temperature of 100.4 b) Increase in the pulse rate from 88-102 bpm c) BP change from 130/88 to 124/80 d) Increase in respiratory rate from 18-22 breaths/min
B An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume.
The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what's wrong with me. I feel terrible. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? a) Suicidal thoughts r/t psychotic ideations b) Post-trauma response r/t traumatic delivery c) Ineffective individual coping r/t hormonal shifts d) Spiritual distress r/t immature belief systems
C This client is showing signs of postpartum blues; one of the main reasons for this problem is related to the hormonal changes that occur after delivery.
Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a) Notify the physician of an impending hemorrhage b) Assess the blood pressure and pulse c) Evaluate the lochia d) Assist the patient in emptying her bladder
D Urinary retention may cause overdistention of the urinary bladder, which lifts and displaces the uterus.
A client is receiving an epidural infusion of a narcotic for pain relief after a C-section. The nurse would report to the anesthesiologist if which of the following were assessed? a) RR of 8 rpm b) Complaint of thirst c) Urinary output of 250 mL/hr d) Numbness of feet and ankles
A The client's RR is below normal.
The nurse is teaching a PP client about breast-feeding. Which instruction should the nurse include? a) The diet should include additional fluids b) Prenatal vitamins should be discontinued c) Soap should be used to cleanse the breasts d) Birth control measures are unnecessary while breastfeeding
A The diet for a breastfeeding client should include additional fluids.
The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? a) Intermittently apply ice packs to her axillae and breasts b) Apply lanolin to her breasts and nipples every 3 hours c) Express milk from the breasts every 3 hours d) Ask the primary HCP to order a milk suppressant
A When cold is applied to the breast, the blood vessels constrict, decreasing the blood supply to the area.
A medication order reads: Methergine 0.2 mg po q6h x 4 doses. Which of the following assessments should be made before administering each dose of this medication? a) Apical pulse b) Lochia flow c) BP d) Episiotomy
c The BP may elevate to dangerous levels.
A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: a) Running warm water on her breasts during a shower b) Applying ice to the breasts for comfort c) Expressing small amounts of milk from the breasts to relieve pressure d) Wearing a loose-fitting bra to prevent nipple irritation
B Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottlefeeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves.
To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? a) Apply antibiotic ointment to the perineum daily b) Change the peripad at each voiding c) Void at least every two hours d) Spray the perineum w/ povidone-iodine after toileting
B Clients should be advised to change their pads at each voiding.
The nurse is preparing to assess the uterine fundus of a client in the immediate PP period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? a) Elevate the client's legs b) Massage fundus until firm c) Ask the client to turn on her left side d) Push on uterus to assist in expressing clots
B Initial intervention is to massage the fundus until firm.
A maternity nurse knows that OB clients are most at high risk for CV compromise during the one hour immediately following a delivery because of which of the following? a) Weight of the uterine body is significantly reduced b) Excess blood volume from pregnancy is circulating in the woman's periphery c) Cervix is fully dilated and the lochia flows freely d) Maternal BP drops precipitously once the baby's head emerges
B Once the placenta is birthed, the reservoir for the mother's larger blood volume is gone.
A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actins by the mother shows that the teaching was effective? a) She pumps her breasts after each feeding b) She feeds her baby every 2-3 hours c) She feeds her baby 10 minutes on each side d) She supplements each feeding w/ formula
B The best way to prevent engorgement is to feed the baby every 2-3 hours.
A postpartum client is diagnosed w/ cystitis. The nurse should plan for which priority action in the care of the client? a) Providing sitz baths b) Encouraging fluid intake c) Placing ice on the perinerum d) Monitoring Hgb/Hct levels
B The client should consume 3000 mL/day if not contraindicated.
During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following S&S should the nurse expect to see? a) Diaphoresis b) Lochia alba c) Cracked nipples d) Hypertension
B The nurse would expect the client would have lochia alba.
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? a) Moderate serosanguinous drainage b) Well-approximated edges c) Ecchymotic area distal to the episiotomy d) An area of redness adjacent to the incision
B The nurse would expect to see well-approximated edges.
A client, G1 P0101, postpartum day 1 is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? a) Notify the woman's primary HCP b) Massage the woman's fundus c) Escort the woman to the bathroom to urinate d) Check the quantity of lochia on the peripad
B This action is the first that the nurse should take.
A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? a) The father may become sad and weepy b) Postpartum blues last about a week or two c) Medications are available to relieve the symptoms d) Very few women experience postpartum blues
B This information is correct. The blues usually resolve within 2 weeks of delivery.
As relates to rubella and Rh issues, nurses should be aware that: a) Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus b) Women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination c) Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant d) Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations
B Women should understand they must practice contraception for 1 month after being vaccinated.
One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. a) The client will drink sufficient quantities of fluid b) The client will have a stable white blood cell count c) The client will have a normal temperature d) The client will have normal-smelling vaginal discharge e) The client will take two or three sitz baths each day.
B, C, D (Self-explanatory)
The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? Select all that apply. a) The woman performs the procedure twice a day b) The woman washes her hands before and after the procedure c) The woman sits in warm tap water for ten minutes three times a day d) The woman sprays her perineum from front to back e) The woman mixes warm tap water w/ hydrogen peroxide
B, D These are both correct.
A client, G2P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? a) Assess her feet and ankles for pitting edema b) Advise the client to stop feeding her baby while her blood pressure is assessed c) Lower both of her legs at the same time d) Measure the length of the episiotomy and document the findings in the chart
C If the legs are removed from the stirrups one at the time, then the woman is at high risk for back and abdominal injuries.
On assessment of a PP client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? a) Document the findings b) Elevate the client's legs c) Massage the fundus until it's firm d) Push on the uterus to assist in expressing clots
C If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm.
Postpartal overdistention of the bladder and urinary retention can lead to which complications? a) Postpartum hemorrhage and eclampsia b) Fever and increased blood pressure c) Postpartum hemorrhage and urinary tract infection d) Urinary tract infection and uterine rupture
C Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to postpartum hemorrhage.
The nurse is assessing a client who is 6hours 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? a) Raise the head of the client's bed b) Obtain Hgb/Hct levels c) Instruct the client to request help when getting out of bed d) Inform the nursery room nurse to avoid bringing the newborn to the client until client's symptoms have subsided
C Orthostatic hypotension may be evident during the first 8 hours after birth.
The day after delivery a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong, "All I do is go to the bathroom." Which of the following is an appropriate nursing response? a) Catheterize the client per doctor's orders b) Measure the client's next voiding c) Inform the client that polyuria is normal d) Check the specific gravity of the next voiding
C Polyuria is normal because the client no longer needs the large blood volume she produced during her pregnancy.
A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists w/ "latch on" and recommends that the mother do which of the following? a) Use a nipple shield at each breastfeeding b) Cleanse the baby's positions at each feed c) Rotate the baby's positions at each feed d) Bottle feed for 2 days then resume breastfeeding
C Rotating positions is one action that can help to minimize the severity of sore nipples.
If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid? a) Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots b) Having the patient flex, extend, and rotate her feet, ankles, and legs c) Having the patient sit in a chair d) Notifying the physician immediately if a positive Homans sign occurs.
C Sitting immobile in a chair will not help.
A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? a) Social deprivation b) Child neglect c) Normal postpartum behavior d) Postpartum depression
C The client is exhibiting normal postpartum behavior.
The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary HCP? a) WBC 12,5000 cells/mm3 b) RBC 4,500,000 cells/mm3 c) Hct 26% d) Hgb 11 g/dL
C The client's Hct is well below normal.
A nurse is examining a 2-day-postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? a) Abnormal involution, lochia rubra heavy b) Abnormal involution, lochia serosa scant c) Normal involution, lochia rubra moderate d) Normal involution, lochia serosa heavy
C The involution is normal and the lochia is rubra.
The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? a) A primiparous client who delivered 4 hours ago b) A multiparous client who delivered 6 hours ago c) A multiparous client who delivered a large baby after oxytocin infusion d) A primiparous client to delivered 6 hours ago and had epidural anesthesia
C The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated w/ PP hemorrhage than the other clients.
A 2-day postpartum mother, G2 P2002, states that her 2 y/o daughter at home is very excited about taking "my baby sister" home. Which of the following is an appropriate response by the nurse? a) "It's always nice when siblings are excited to have the babies go home." b) "Your daughter is very advanced for her age. She must speak very well." c) "Your daughter is likely to become very jealous of the new baby." d) "Older sisters can be very helpful. They love to play mother."
C The nurse should forewarn the mother about the likelihood of the 2 y/o's jealousy.
On admission to the L&D unit, a client's Hgb was assessed at 11.0 g/dL, and her Hct at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? a) Hgb 12.5 g/dL, Hct 37% b) Hgb 11.0 g/dL, Hct 33% c) Hgb 10.5 g/dL, Hct 31% d) Hgb 9.0 g/dL, Hct 27%
C The nurse would expect these values - a slight decrease in both Hgb and Hct values.
A client has just been transferred to the postpartum unit from L&D. Which of the following tasks should the RN delegate to the nursing care assistant? a) Assess client's fundal height b) Teach client how to massage her fundus c) Take the client's vital signs d) Document quantity of lochia in the chart
C This action can be delegated to a nursing assistant.
A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? a) The client will breastfeed her baby every 2 hours b) The client will consume a normal diet c) The client will have moderate lochial flow d) The client will ambulate to the bathroom every 2 hours
C This is the most important goal.
A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, I'm bleeding a lot. The most likely cause of postpartum hemorrhage in this woman is: a) Retained placental fragments b) Unrepaired vaginal lacerations c) Uterine atony d) Puerperal infection
C This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony.
The PP nurse is assessing a client who delivered a healthy infant by CS for S&S of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? a) Paleness of the calf area b) Coolness of the calf area c) Enlarged, hardened veins d) Palpable dorsalis pedis pulses
C Thrombosis of superficial veins is usually accompanied by S&S of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein.
A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? a) Do nothing; this a normal finding b) Massage the woman's fundus c) Take the woman to the bathroom to void d) Notify the woman's HCP
D Because of the heavy lochia, the nurse should notify the woman's HCP.
The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? a) 1/2 cup raw celery dipped in 1 ounce cream cheese b) 8 ounce yogurt mixed w/ one medium banana c) 12 ounce strawberry milk shake d) 1 1/2 cup raw broccoli
D Broccoli is very high in vitamin A and also contains iron.
The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? a) Provide the client w/ a nutritious meal b) Encourage the client to take a nap c) Assist the client w/ ADLs d) Assure the client that she is an excellent mother
D Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby.
A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? a) "That is very concerning. I will request that your physician order an enema for you." b) "Two days is not that bad. Some patients go four days or longer without a movement." c) "You have been taking antibiotics through your intravenous. That is probably why you are constipated." d) "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."
D Consuming fluid and fiber and exercising all help clients reestablish normal bowel function.
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours PP and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? a) Document the finding b) Encourage the client to ambulate c) Encourage the client to increase fluid intake d) Contact the HCP and inform HCP of this finding
D Excessive = menstrual pad saturated in 15 minutes (postpartum hemorrhage).
The nurse is caring for four 1-day PP clients. Which client assessment requires the need for follow-up? a) The client w/ mild afterpains b) The client w/ pulse rate of 60 bpm c) The client w/ colostrum discharge from both breasts d) The client w/ lochia that is red and has foul-smelling odor
D Foul-smelling or purulent lochia usually indicates infection, and these findings aren't normal.
A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her infant. Which of the following responses by the nurse is appropriate? a) Suggest that the woman bottlefeed for a few days b) Instruct the patient on how to massage her fundus c) Instruct the patient to feed using an alternate position d) Discuss the action of breastfeeding hormones
D The nurse should discuss the action of oxytocin.
A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a) The woman is a gravida 2, para 2 b) The woman had a vacuum-assisted birth c) The woman received epidural anesthesia d) The woman has an episiotomy
D These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids.
