High-Risk Postpartum- Davis Practice Q's

A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose? 1. Vitamin K. 2. Protamine. 3. Vitamin E. 4. Mannitol.

2. Protamine is the antidote for heparin overdose. When heparin is admin- istered, clients must be monitored care- fully for signs of hemorrhage. Protamine is the antidote for heparin overdose. Conversely, the antidote for Coumadin, another medication often administered to clients with DVT, is vitamin K.

A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing, because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes.

2. The nurse should notify the physician of the signs of preeclampsia. The hypertensive ill- nesses of pregnancy can develop at any time after 20 weeks' gestation through about 2 weeks postpartum. This client is exhibiting a late onset of preeclampsia— markedly elevated blood pressure and hyperreflexia. The physician should be notified of the changes.

A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104 bpm. 2. Urinary output 240 mL/12 hr. 3. Blood pressure 160/120. 4. Temperature 100°F.

2. The urinary output is the likely cause of the client's changes. The hourly output for this client is 20 mL/hr. This is well below the minimum urinary output of 30 mL/hr. Because the medication is excreted via the kidneys, when a client's output is low, the concentration of the medication can increase to toxic levels in the bloodstream. This client is exhibiting signs of magne- sium toxicity.

A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time? 1. Tell the father that his behavior is inappropriate. 2. Sit with the family and quietly communicate sorrow at their loss. 3. Help the couple to understand that their daughter is acting inappropriately. 4. Encourage the couple to send their daughter to her grandparents.

2. This action is appropriate. The nurse is acknowledging that every member of the family is grieving the loss. Each member of a family will grieve differently. One of the important actions for the nurse is to help the members of the family to communi- cate with one another. Children do not understand the finality of death until about age 9, but pre-schoolage children often feel guilty when bad things happen. It is important for the nurse to communi- cate clearly that the child was not respon- sible for the death of the fetus.

A client on the postpartum unit has been diagnosed with deep vein thrombosis. The following titration schedule is included in the client's orders: If INR is less than 1: administer 7,500 units heparin subcu If INR is 1.1 to 2: administer 5,000 units heparin subcu If INR is 2.1 to 3: administer 2,500 units heparin subcu If INR is greater than 3: administer 0 units heparin subcu The client's INR is 2.6. How many mL of heparin will the nurse administer if the available concentration of heparin is 5,000 units per 0.2 mL? (Calculate to the nearest tenth.) __________ mL.

0.1 mL Because the INR is between 2.1 and 3, the nurse must administer 2,500 units of heparin subcu. To determine the quantity of heparin that the nurse must administer, a ratio and proportion equation should be set up: Known dose = Desired dose Known volume = Desired volume 5,000 units = 2,500 units 0.2 x mL 5,000 x = 2,500 × 0.2 x = 2,500 × 0.2 5,000 x = 0.1 mL The test taker should not let the titration protocol confuse him or her. The test taker simply must choose the dosage that meets the given criteria. Because the INR in the scenario is 2.6, the test taker can quickly see that the dosage that must be administered is 2,500 units: 2.1 < 2.6 < 3.

A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply. 1. Look up the client's blood type in the chart. 2. Check the client's arm bracelet. 3. Check the blood type on the infusion bag. 4. Obtain an infusion bag of dextrose and water. 5. Document the time the infusion begins.

1, 2, 3, and 5 are correct. 1. The nurse must check the client's blood type. 2. The nurse must check the client's name by checking the bracelet and asking the client her name. 3. The nurse must compare the client's blood type with the blood type on the infusion bag. 5. The time the infusion begins and ends must be documented. TEST-TAKING TIP: The potential for blood transfusion incompatibility is very real. It is essential, therefore, that two health care practitioners check simultaneously to make sure that the client is receiving the correct blood. If any sign of a reaction should develop, the transfusion should be stopped immediately. Only normal saline solution is used as a solution immediately before or after blood administration. Dextrose in water will hemolyze the red blood cells. In addition, a special filtered infusion set must be used.

A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply. 1. Fever. 2. Flank pain. 3. Dark-colored urine. 4. Swelling at the injection site. 5. Polycythemia.

1. Fever. 2. Flank pain. 3. Dark-colored urine. When RhoGAM is administered to an Rh+ (positive) client, antibodies against the client's red blood cells are being injected into her body. A hemolytic response similar to one seen when a client receives the wrong type of blood may develop.

A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

1. Foul-smelling lochia is a sign of endometritis. Some nursing actions are dependent functions. For example, nurses are able to administer antibiotics only after receiving a physician's order. Other actions, however, are independent actions. For example, assisting a client with engorged breasts to self-express breast milk, to apply warm soaks to the breasts, and to breastfeed effectively are independent actions. The nurse must report foul-smelling lochia to the physician so that the doctor can decide whether to order antibiotics for the client.

A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful? 1. The mother's nipples are soft to the touch. 2. The baby swallows after every 5th suck. 3. The baby's pre- and postfeed weight change is 20 milliliters. 4. The mother squeezes her nipples during manual expression.

1. If the woman has manually removed milk from her breasts, her nipples will soften to the touch. This client is complaining of engorgement. The baby is having difficulty latching because the breast is inflamed, making the nipple tense and short. When the woman manually removes a small amount of the foremilk, the nipple becomes easier for the baby to grasp.

A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

1. Serial grip strengths can be performed to monitor a client for magnesium sulfate toxicity. The only accurate way to assess for magnesium toxicity is to do a serum magnesium level. Normal magnesium levels are 1.8 to 3.0 mg/dL. Therapeutic levels are 4 to 8 mg/dL. Reflex depression begins to appear when the levels reach 8 to 12 mg/dL. When levels rise to 15 mg/dL or higher, respira- tory depression and, eventually, cardiac arrest occur. Hourly grip strengths per- formed with reflex assessments are excellent noninvasive assessments to monitor for neuromuscular blockage. If changes are noted, the nurse can notify the health care provider, who can order a stat magnesium level.

A client is receiving a blood transfusion after the delivery of a placenta accreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion? 1. "My lower back hurts all of a sudden." 2. "My hands feel so cold." 3. "I feel like my heart is beating fast." 4. "I feel like I need to have a bowel movement."

1. Sudden lower back pain is a sign of a transfusion reaction. If the client is receiving the wrong type blood or is allergic to the blood, she will develop flank or kidney pain. Antibodies in the client's blood are likely destroying the donated blood. The transfusion should be stopped immediately and the reaction reported to the physician and to the blood bank.

A client, who had no prenatal care, delivers a 10-lb 10-oz baby boy whose serum glucose result 1 hour after delivery was 20 mg/dL. Based on these data, which of the following tests should the mother have at her 6-week postpartum checkup? 1. Glucose tolerance test. 2. Indirect Coombs' test. 3. Blood urea nitrogen (BUN). 4. Complete blood count (CBC).

1. The client should have a glucose tolerance test done at about 6 weeks postpartum. Women who give birth to hypoglycemic and/or macrosomic babies are at increased risk of developing type 2 diabetes. The baby born to this mother is hypoglycemic and is macro- somic. The most common cause of these two neonatal complications is maternal diabetes. It is recommended that mothers who are diabetic during pregnancy—that is, gestational diabetics—be assessed for type 2 diabetes at about 6 weeks postpartum.

The physician declares after delivering the placenta of a client during a cesarean section that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2,000 mL. 2. Blood pressure of 160/110. 3. Jaundiced skin color. 4. Shortened prothrombin time.

1. The client with a placenta accreta is high risk for a large blood loss. A placenta accreta's chorionic villi burrow through the endometrial lining into the myometrial lining. Separation of the placenta from the uterine wall is severely hampered. Clients often lose large quantities of blood, and it is not uncommon for the physician to have to perform a hysterec- tomy to control the bleeding. Clients who have had multiple uterine scars are especially at high risk for this problem. If the test taker were unfamiliar with placenta accreta, he or she could deduce the answer, because the placenta is highly vascular and only one answer referred to a vascular issue. The average blood loss during a cesarean delivery is 1,000 mL.

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? 1. Gently massage the areas toward the nipple, especially during feedings. 2. Apply ice to the areas between feedings. 3. Bottle feed for the next twenty-four hours. 4. Apply lanolin ointment to the areas after each and every breastfeeding

1. This answer is correct. She should gently massage the area toward the nipple. A client who palpates a tender, hard nodule in her lactating breast is experiencing milk stasis. The stasis may be related to a blocked milk duct. It is very important that the woman gently massage the nodule while applying warm soaks and/or feeding her baby to prevent mastitis from developing.

A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding? 1. The mother states, "I'm so tired. Please feed the baby in the nursery for me." 2. The mother states, "Her eyes look like mine, but her chin is her Dad's." 3. The mother says, "We have decided to name her Sarah after my mother." 4. The mother says, "I breastfed her. I still need help swaddling her, though."

1. This statement by the mother may be a true statement, but it may communicate the mother's difficulty with accepting her baby. Babies with defects are more likely to be victims of child abuse and neglect than are healthy, normal babies. Nurses must evaluate the bonding between the mother and her baby. If the nurse is concerned about the bonding relationship, he or she must monitor the mother's care and, if necessary, refer the family for a home-care nurse evaluation and/or to child protective services.

A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply. 1. G1 P0000, delivered a fetal demise at 29 weeks' gestation. 2. G2 P1001, prolonged first stage of labor. 3. G2 P0010, delivered by cesarean section for failure to progress. 4. G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate. 5. G4 P3003, with a succenturiate placenta.

2. Clients who have had a prolonged first stage of labor are at high risk for post- partum hemorrhage (PPH). 5. Clients with a succenturiate placenta are at high risk for PPH. TEST-TAKING TIP: The muscles of the uterus of a client who has experienced a prolonged first stage of labor are fatigued. In the postpartum period, therefore, they may fail to contract fully enough to control bleeding at the site of placental separation. A succenturiate placenta is characterized by one primary placenta that is attached via blood vessels to satellite lobe(s). These clients must be monitored carefully for postpartum hemorrhage.

A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6°F, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority? 1. Ineffective breastfeeding. 2. Infection. 3. Ineffective individual coping. 4. Pain

2. Infection is the priority nursing diag- nosis. A temperature of 104.6°F, as well as the client's other signs/symptoms, should immediately suggest the presence of infection. This client has a breast abscess. Although all of the nursing diag- noses are important, the most important diagnosis is infection. It is the only one of the four diagnoses that is related to the acute problem. Ineffective breastfeeding contributed to the development of the infection. Because of the infection, the client is in pain and is coping poorly. Once the abscess is drained and the antibiotics have been administered, the other three diagnoses will be on the road to being resolved.

The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? 1. Massage the uterus. 2. Notify the obstetrician. 3. Administer an oxytocic as ordered. 4. Assist the client to the bathroom.

2. It is important for the nurse to notify the physician. The client is bleeding more than she should after the delivery. The nurse must act as a detective to determine why he or she is seeing symptoms. In this scenario, the uterus is contracted and at the expected location—that is, firm at the umbilicus. The lochia flow, however, is heavy. The nurse must notify the practitioner for assistance because there is no additional action the nurse can take at this time.

A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding? 1. Have the woman wean the baby to formula. 2. Have the baby stay in the hospital room with the mother. 3. Have the woman pump and dump her milk for two weeks. 4. Have the baby bottle fed milk that the mother has stored.

2. Optimally, the baby should stay in the hospital room with the mother. Other than the period of time that the mother is in the surgical suite, there is unlikely to be anything that would warrant separating the mother from her baby. The surgeon and anesthesiologist should be able to prescribe medicines that are compatible with breastfeeding. Plus, the client could easily feed her baby while lying in a comfortable position. The client should be admitted to a hospital room that would be safe for a 6-week-old baby.

The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug? 1. Monitor the urinary output hourly. 2. Supervise while the woman holds her newborn. 3. Position the woman slightly elevated on her left side. 4. Ask any visitors to leave the room.

2. Supervise while the woman holds her newborn. Benadryl is an antihista- mine. One of the common side effects of Benadryl is sedation. It is very likely that this client will fall asleep while holding the baby. The nurse, therefore, should super- vise the mother while she holds her baby.

. A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following laboratory values indicates that the medication is effective? 1. PT (prothrombin time): 12 sec (normal is 10-13 seconds). 2. INR (international normalized ratio): 2.5 (normal is 1.0-1.4). 3. Hematocrit 55%. 4. Hemoglobin 10 g/dL.

2. The INR should be between 2 and 3. Coumadin interferes with the clotting of blood. The PT and/or INR will be monitored to determine whether the medication is effective. If the PT is more than 2 times normal or the INR is over 3, the client is at high risk for hemorrhage.

A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible.

2. The action is appropriate. The woman should breastfeed frequently. Mastitis is a breast infection. Usually only one duct system is affected by the bacteria. If the mother were to wean abruptly, milk stasis would occur, the bacteria would proliferate, and a breast abscess is likely to develop. The mother should feed her baby frequently, use warm soaks to promote milk flow, and notify her obstetrician. Antibiotics are usually prescribed to eradicate the bacteria.

A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk? 1. Hemorrhage. 2. Stroke. 3. Endometritis. 4. Hematoma.

2. The client is at high risk for stroke if a clot should travel to the brain through the vascular tree. The test taker could deduce the answer to this question by determining the etiology of each of the problems. The only complication that is caused by a clot, which is the same etiology as the DVT, is a stroke.

A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform? 1. Cover the wound with sterile wet dressings. 2. Notify the surgeon. 3. Elevate the head of the client's bed slightly. 4. Flex the client's knees.

2. The highest priority action is to notify the surgeon. Positioning of the client is important, as the nurse wants to take as much stress off the incision as possible. If the surgeon is delayed, and the dehiscence is significant, the nurse must keep the intestines moist by placing sterile dressings that have been wetted with sterile saline, over the area (see

A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman? 374 MATERNAL AND NEWBORN SUCCESS 1. Endometrial ischemia. 2. Postpartum hemorrhage. 3. Prolapsed uterus. 4. Vaginal hematoma

2. The nurse should carefully monitor this client for signs of postpartum hemorrhage. Because a succenturiate placenta has extra lobe(s), the client is at high risk for hemorrhage from one or more of the lobes. The professional who performed the delivery may have noted one lobe but may not have realized that an additional lobe is still in utero.

Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration is comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role.

3. Fluid volume deficit related to blood loss is the priority nursing diagnosis. It is likely that most clients will have multiple nursing diag- noses. The nurse must then determine which is (are) the priority diagnosis(ses). It is essential that the nurse remember Maslow's Hierarchy of Needs. Although psychosocial needs are very important, the physiological needs, especially those related to the respiratory and the cardio- vascular systems, must take precedence.

A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for? 1. Pruritus. 2. Nausea. 3. Postural headache. 4. Respiratory depression.

3. The client who has had the spinal anesthesia is much more likely to develop a postural headache than a client who had epidural anesthesia. Both spinal anesthesia and epidural anesthesia are forms of regional anesthesia. The same medication is used and it is placed at the same verte- bral level in both instances. Only spinal anesthesia is administered into the spinal space, leaving a wound through which spinal fluid can escape. When spinal fluid is lost from the spinal canal, clients are at high risk for developing postural headaches, also called spinal headaches, because of the change in pressure in the spinal canal.

The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen (hPL). 4. Human chorionic gonadotropin (hCG).

3. The drop in human placental lactogen (hPL) is related to the glucose level. The hormone hPL is an insulin antagonist. Throughout pregnancy, the insulin needs of type 1 diabetics rise incrementally as the levels of hPL in the bloodstream rise. Once the placenta is birthed, however, the levels drop precipi- tously. As a result, it is not uncommon for the glucose levels of type 1 diabetics to be within normal limits for a day or so after delivery—as seen in this client.

A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time.

3. The fundal response indicates that the medication was effective in contracting the uterus. Methergine is an oxytocic agent. It is administered after delivery if the uterus is atonic or if the client is high risk for uterine atony. When the uterus is noted to be well contracted and at the appropriate position in the abdomen, the nurse can conclude that the medication action was successful.

A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first? 1. Give two breaths. 2. Discontinue medications. 3. Call a code. 4. Check carotid pulse.

3. The nurse should call a code first. The nurse should call a code as soon as he or she discovers a client who is nonresponsive. Immediately after calling the code, the nurse should stop the medications, begin rescue breathing, and provide chest compressions, if necessary, until the code team arrives. Only after receiving an order to do so should the nurse administer calcium gluconate, the antidote to magnesium sulfate.

The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings? 1. Temperature is elevated, a sign of infection. 2. Pulse is too low, a sign of vagal pathology. 3. Respirations are too low, a sign of medication toxicity. 4. Blood pressure is elevated, a sign of preeclampsia.

3. The respiratory rate of 12 is well below normal. Peripartum clients' respiratory rates average 20 rpm. Even though explanations are provided for each of the signs, the test taker must be able to determine which explanation is correct and which are erroneous. If the test taker consciously stops to think about each of the signs before looking at the explanations, he or she is less likely to be swayed by a wrong answer.

A serum electrolyte report for a client, 1 day post-cesarean delivery for eclampsia, has just been received by the nurse. The client is receiving 5% dextrose in 1 /2 normal saline IV at 125 mL/hr and magnesium sulfate 2 G/hr IV via infusion pump. Which of the following values should the nurse report to the surgeon? 1. Magnesium 7 mg/dL. 2. Sodium 136 mg/dL. 3. Potassium 3.0 mg/dL. 4. Calcium 9 mg/dL.

3. The serum potassium is below normal. The nurse should report the finding to the physician. The test taker should be familiar with the normal values of commonly tested electrolytes. Although the normal magnesium level is 1.8 to 3.0 mg/dL, magnesium sulfate is being administered to raise the level in the client's bloodstream. The medication, which is an anticonvulsant, is being administered to prevent further seizures. The potassium level, however, is well below normal.

The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? 1. Failed lactogenesis. 2. Dysfunctional parenting. 3. Wound dehiscence. 4. Projectile vomiting.

3. This client is at high risk for wound dehiscence. Her wound healing may be impaired because of her diabetes and because of her obesity. The fact that this client is postoperative cesarean section is irrelevant. This question could have been written by a surgical nursing professor rather than a parent-child nursing professor. The important pieces of information needed to answer this question correctly are that this client is obese and a type 1 diabetic and that she has had surgery.

A client who received a spinal for her cesarean delivery is complaining of pruritus and has a macular rash on her face and arms. Which of the following medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Zofran (ondansetron). 3. Compazine (prochlorperazine). 4. Benadryl (diphenhydramine).

4. Benadryl is an antihistamine. It is the drug of choice for this client who has pruritus and a rash. To answer this question, the test taker must first determine what the client's clinical problem is and then determine which medication will relieve that problem. The test taker, therefore, must be familiar with the actions of major medications. The client is exhibiting signs of an allergic response. Benadryl is the only choice that will inhibit the client's immune response.

A rubella nonimmune, breastfeeding client has just received the rubella vaccine. Which of the following side effects should the nurse warn the client about? 1. The baby may develop a rash a week after the shot. 2. The baby may temporarily reject the breast milk. 3. The mother's milk supply may decrease precipitously. 4. The mother's joints may become painful and stiff.

4. One out of 4 women complains of painful and stiff joints after receiving the injection. Even though the benefits of receiving immunizations far outweigh the side effects of the medicines, anyone who receives a vaccine should be advised of the potential complications. It is especially important for mothers who are taking home newborn infants to receive anticipatory guidance regarding these changes and to be told that the baby's health will not be compromised.

A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby's and mother's infection? 1. Staphylococcus aureus. 2. Streptococcus pneumoniae. 3. Escherichia coli. 4. Candida albicans.

4. The baby and mother are infected with Candida albicans. TEST-TAKING TIP: When breastfeeding babies develop thrush, the mothers are at high risk for developing a yeast infection of the breast. Because they are both infected, it is critical that they be treated simultaneously for a minimum of 2 weeks. If they are not treated aggressively, they will continue to reinfect each other.

On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client? 1. "Have you ever had anesthesia before?" 2. "Do you have any allergies?" 3. "Do you scar easily?" 4. "Are there many stairs in your home?"

4. The client has had major surgery. The client will need some assistance when she returns home, especially if she has a number of stairs to climb. TEST-TAKING TIP: Discharge care must begin on admission to the hospital. Cesarean section clients will need some assistance after discharge, especially if they must climb up and down stairs.

A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority? 1. Lochia is serosa. 2. Client cries throughout the visit. 3. Nipples are cracked. 4. Client yells at the baby for crying.

4. The client is exhibiting inappropriate behavior when she yells at the baby for crying. The nurse must make additional assessments to determine whether there is any other evidence of abuse or neglect. TEST-TAKING TIP: The baby is the most vulnerable member of the mother-infant dyad. Because the baby is completely dependent on the care of the mother, if the nurse discovers any behavior or other evidence that makes him or her suspicious of child abuse or neglect, he or she is obligated both morally and legally to report the situation. Clients who are experiencing postpartum depression usually perform baby care competently.

The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching by the nurse in the hospital was successful? 1. The client is breastfeeding her baby every two hours. 2. The client is using a diaphragm for family planning. 3. The client is taking her temperature every morning. 4. The client is seeking care for a recent weight loss.

4. The client should seek care for a recent weight loss. This may be a symptom of full-blown AIDS. TEST-TAKING TIP: Although obstetric clients who enter the hospital are usually aware of their HIV status, the nurse must still review the actions that clients should take after discharge. These actions include taking all medications, bottle feeding rather than breastfeeding, and reporting any changes in health, like weight loss or the appearance of thrush.

The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby who exhibited visible birth defects. Which of the following actions by the nurse is appropriate? 1. Discourage the parents from naming the baby. 2. Advise the parents that the baby's defects would be too upsetting for them to see. 3. Transport the baby to the morgue as soon as possible. 4. Give the parents a lock of the baby's hair and a copy of the footprint sheet.

4. This is appropriate. The small mementos will provide the couple with something tangible to remember the pregnancy and baby by. TEST-TAKING TIP: It is very difficult for parents who have delivered a fetal demise. The only contact they have had with the baby is through the pregnancy. Small mementos, such as a picture, lock of hair, or baby bracelet, provide the parents with tangible remembrances of the baby.

A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is "bleeding and saturating a pad about every 1/2 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bed rest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please go to the emergency department."

4. This is the correct response. This client needs to be evaluated. The quantity of lochia discharge is usually described as scant, moderate, or heavy. A heavy discharge is described as a discharge that saturates a pad in 1 hour or less. Because this client's lochia has already changed to alba (whitish), it is especially concerning that she is now experiencing a heavy lochia rubra (reddish) flow.

A client is receiving an IV heparin drip at 16 mL/hr via an infusion pump for a diagnosis of deep vein thrombosis. The label on the 1 /2 liter bag of D5W indicates 25,000 units of heparin have been added. How many units of heparin is the client receiving per hour? (Calculate to the nearest whole.) __________ units per hour.

800 units/hour The formula to determine the number of units that the client is receiving per hour is: total number of units : mL of IV solution = x units : flow rate 25,000 units : 500 mL = x : 16 mL/hr 500 x = 25,000 × 16 x = 25,000 × 16 500 x = 800 units/hr To make sure that he or she is calculating the amount correctly, the test taker can label each number and cancel to make sure that the result is in the units requested. As can be seen above, the mL's drop out and the values that are left are units/hr.

3. A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? Select all that apply. 1. Hyperthermia. 2. Diarrhea. 3. Hypotension. 4. Palpitations. 5. Anasarca.

1 and 2 are correct. 1. Hemabate can cause nausea, vomiting, diarrhea, and hyperthermia. 2. Hemabate can cause nausea, vomiting, diarrhea, and hyperthermia. Hemabate is an oxytocic agent that acts on the myometrial tissue of the uterus. During the postpartum it acts directly at the site of placental separation to stop uncontrolled bleeding. Hemabate is a type of prostaglandin.

A woman who wishes to breastfeed advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate? 1. Advise the woman that unfortunately she will be unable to breastfeed. 2. Examine the woman's breasts to see where the incision was placed. 3. Monitor the baby's daily weights for excessive weight loss. 4. Inform the woman that reduction surgery rarely affects milk transfer

3. During breast reduc- tion surgery, fat tissue is removed from the breast. Because the breast is much smaller, the nipple must be moved to a new location. During these procedures, the client's mammary ducts may be ligated. If the ducts are severed, the woman will not be able to transfer the milk produced in her glandular tissue to the baby. The most objective means of assessing milk transfer is by closely monitoring the baby's weights. Prefeed and postfeed weights as well as daily weights should be monitored.

Cloxacillin 500 mg by mouth four times per day for 10 days has been ordered for a client with a breast abscess. The client states that she is unable to swallow pills. The oral solution is available as 125 mg/5 mL. How many mL of medicine should the woman take per dose? (Calculate to the nearest whole.) ______ mL per dose.

Known dosage = Desired dosage Known volume Desired volume 125 mg = 500 mg 5 mL x mL 125 x = 5 × 500 125 x = 2,500 x = 20 mL per dose TEST-TAKING TIP: The test taker must remember that a dose is defined as the quantity of medication that is adminis- tered to a client at one time. The client, then, is to receive 500 mg, or 20 mL, of the medication at each administration.

The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the client who had which of the following deliveries asks why she must receive a RhoGAM injection? Select all that apply. 1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 4. Birth of Rh-negative twins at 35 weeks' gestation. 5. Delivery of a 40-week-gestation, Rh-positive baby

1, 2, 3, and 5 are correct. 1. The client should receive a RhoGAM injection after a spontaneous abortion. 2. The client should receive a RhoGAM injection after an amniocentesis. 3. The client should receive a RhoGAM injection after the delivery of a fetal demise. 5. The client should receive a RhoGAM injection after birth of an Rh-positive baby. RhoGAM, or Rh immune globulin, is administered to pregnant women at 28 weeks' gestation; after any invasive procedure, like an amniocentesis; after a preterm disruption of a pregnancy, like abortion or placental previa bleed; and after the delivery of an Rh+ infant. Because Rh-negative infants carry no Rh antigen, it is unnecessary to administer RhoGAM to their Rh-negative mothers.

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 1. Hallucinations. 2. Polyphagia. 3. Induced vomiting. 4. Weepy sadness.

1. The client with postpartum psychosis will experience hallucinations. Clients who have been diagnosed with postpartum psychosis have a psychiatric disease. They experience hallucinations, usually auditory, including voices that may tell them to kill their babies.

A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for the past 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.

1. This output is below the accepted minimum for 8 hours. The nurse must divide the amount of urine output by the number of hours. The output in the scenario is equal to 25 mL/hr. This is well below the accepted output of 30 mL/hr. Plus, because this is a postpartum client, the nurse would expect high urinary outputs. Postpartum clients often have slowed heartbeats.

A client who has been diagnosed with deep vein thrombosis has been ordered to receive 12 units heparin/min. The nurse receives a 500-mL bag of D5W with 20,000 units of heparin added from the pharmacy. At what rate in mL/hr should the nurse set the infusion pump? (Calculate to the nearest whole.) __________ mL/hr.

18 mL/hour. The formula for determining the flow rate is: Total number of units : mL of IV solution = Units/min : x flow rate 20,000 units : 500 mL = 12 units/min : x mL/hr Because the order is written in units/min, the test taker must determine how many units the client is receiving per hour: (12 units/min × 60 min/hr = 720 units/hr) 20,000 units : 500 mL = 720 units/hr : x 20,000 x units = 500 mL × 720 units/hr x = 500 mL × 720 units/hr 20,000 units x = 18 mL/hr TEST-TAKING TIP: The test taker must remember that pumps are always pro- grammed in mL/hr. Because the question included a rate of units/min, to calculate the pump rate, units/min had to be con- verted to units/hr. In addition, it must be remembered that per a Joint Commission on Accreditation of Hospitals directive, "units" must always be written out fully— that is, not abbreviated as "U."

Which of the following comments suggest that a client whose baby was born with a congenital defect is in the bargaining phase of grief? 1. "I hate myself. I caused my baby to be sick." 2. "I'll take him to a specialist. Then he will get better." 3. "I can't seem to stop crying." 4. "This can't be happening."

2. This client is exhibiting the bargaining stage of grief. Although clients do not go through the stages of grief linearly, they do express the many stages of grief while they mourn the loss of their child of fantasy. Bargaining is a particularly vulnerable time for parents. Unscrupulous practitioners can make a great deal of money from couples who believe that their child can be cured from "special medicines" or "procedures."

A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain.

2. This is the priority nursing diagnosis. Because the baby is macrosomic, the client is high risk for uterine atony that could lead to heavy vaginal bleeding possibly resulting in fluid volume deficit. If the test taker remembers CAB as taught in CPR class—circulation, airway, breathing—he or she would realize that the client's fluid volume—that is, circulation—must take precedence.

A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? 1. Place the client flat in bed. 2. Assess for dependent edema. 3. Auscultate lung fields. 4. Check patellar reflexes.

3. It is important for the nurse to auscultate the client's lung fields every 4 hours to assess for rales. A cesarean section client is a postoperative client as well as a postpartum client. The nurse must perform needed physiological assess- ments. Because this client had general anesthesia during her surgery, she is high risk for pulmonary complications, including atelectasis and pneumonia.

A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus? 1. Abdominal striae. 2. Oliguria. 3. Omphalocele. 4. Absent bowel sounds

4. An absence of bowel sounds may indi- cate that a client has a paralytic ileus. TEST-TAKING TIP: One of the complications of surgery and/or anesthesia is a paralytic ileus, the cessation of intestinal peristalsis. The client should be given nothing by mouth. Among other interventions, a nasogastric tube may be inserted to provide relief.

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client? 1. The woman should never be left alone with her infant. 2. Symptoms rarely last more than one week. 3. Clinical response to medications is usually poor. 4. The woman must have her vitals assessed every two days.

1. It is essential that the client never be left alone with her baby. Clients who have been diagnosed with postpartum psychosis have been known to have homicidal and suicidal ideations. Because the baby and other children are vulnerable, the mother should always be supervised when in their presence. In addition, if she exhibits suicidal behaviors, she should be supervised at all times.

A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following prn medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Demerol (meperidine). 3. Seconal (secobarbital). 4. Benadryl (diphenhydramine).

1. Reglan is an antiemetic. It is one drug that may be administered to a client who is vomiting after surgery. This client is exhibiting a common side effect of regional anesthesia: nausea and vomiting. Antiemetics are the medications of choice for this problem. Many prn medications are ordered for postsurgical clients. The test taker must become familiar with the actions and the uses of each of them.

A nurse is assessing a 1-day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic.

1. The client should be assessed by her health care practitioner. This client is complain- ing of an excessive amount of pain after having received a relatively large dose of ibuprofen. Because the perineum is edematous, the lochial flow is normal, and the pain level is well above that expected, the nurse should suspect that the client has developed a hematoma. The client should be assessed by her health care provider.

A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 3. Ask the woman if she would like the doctor to prescribe a sedative for her. 4. Remove the baby from the delivery room as quickly as possible.

2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. The nurse should treat this baby with care and concern. Even though the baby has died he is still a valued child to the parents. The parents should be asked whether they would like to see or hold their baby. If they would, the nurse should help the parents to see the normalcy in their baby. Sedating a client only delays her inevitable grief.

A client is 3 days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective? 1. The client has had no seizures since delivery. 2. The client's blood pressure has dropped from 160/120 to 130/90. 3. The client's postoperative weight has dropped from 154 to 144 lb. 4. The client states that her headache is gone.

2. Hydralazine is an antihypertensive. The change in blood pressure indicates that the medication is effective. Hydralazine is an anti- hypertensive medication. The goal, therefore, is for the blood pressure to drop. A change in BP from 160/120 to 130/90 is evidence of a therapeutic effect.

A mother, G4 P4004, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis

2. The client should be monitored carefully for signs of postpartum hemorrhage. An average size baby weighs 2,500 to 4,000 grams. The baby in the scenario is macrosomic. As a result, the mother's uterus has been stretched beyond its expected capacity. The client is, therefore, at high risk for uterine atony, which could result in a postpartum hemorrhage.

A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action? 1. Postpartum hemorrhage. 2. Severe postural headache. 3. Pruritic skin rash. 4. Paralytic ileus.

2. The nurse would expect the client to complain of a severe postural headache. Postpartum hemorrhage, pruritic rash, and paralytic ileus are complications seen in post-cesarean clients, whether they received general anesthesia, epidural anesthesia, or spinal anesthesia. Only spinal clients, most notably those who elevate soon after surgery, are at high risk for postural headaches.

A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication? 1. Chamomile tea can potentiate the affect of the drug. 2. Therapeutic effect may be delayed a week or more. 3. The medication should only be taken whole. 4. A weight gain of up to ten pounds is commonly seen.

2. The therapeutic effect of selective serotonin receptor inhibitors (SSRIs) like Zoloft is delayed about 1 to 2 weeks from the time the medication is initiated. Clients who receive medications for emotional problems as well as for physiological complaints expect to experience resolution of their symptoms in a timely fashion. If postpartum depression clients are not forewarned of the delay of the therapeutic effects, they may stop taking the medications prematurely, believing that the medicines are useless.

A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O− (negative), the baby's type is A+ (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate? 1. Advise the client to keep her physician appointment at the end of the week to receive her RhoGAM injection. 2. Make sure that the client receives a RhoGAM injection before she is discharged from the hospital. 3. Notify the client that because her baby's Coombs' test was negative she will not receive an injection of RhoGAM. 4. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.

2. This response is correct. The nurse should not finalize an Rh- (negative) client's discharge until the client has received her RhoGAM injection. The administration of RhoGAM is the only way to prevent an Rh- (negative) client's body from mounting a full antibody response to the delivery of an Rh+ (positive) baby. It is malpractice for a nurse to discharge the client before she receives her injection or to delay the injection beyond the 72-hour deadline.

The nurse should expect to observe which behavior in a 3-week-multigravid postpartum client with postpartum depression? 1. Feelings of infanticide. 2. Difficulty with breastfeeding latch. 3. Feelings of failure as a mother. 4. Concerns about sibling jealousy

3. Mothers who experience postpartum depression often do feel like failures. If a mother who is diagnosed with postpartum depression does have difficulty latching her baby to the breast, she may view this as yet another example of her poor parenting skills. The difficulty itself, however, is unrelated to the diagnosis.

A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period? 1. Infection. 2. Bloody urine. 3. Heavy lochia. 4. Rectal abrasions.

3. The client should be monitored care- fully for heavy lochia. The key to answering this question is the time frame stipulated in the stem of the question—"the imme- diate postpartum period." There are two main maternal complications associated with forceps use—hemorrhage and infection. Hemorrhage usually occurs early, secondary to cervical, vaginal, or perineal lacerations. Infection usually develops later in the postpartum period secondary to contamination of the uterine cavity during the application of the forceps.

In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)? 1. The woman complains of numbness in the toes and heel of one foot. 2. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. 3. One of the woman's calves is swollen, red, and warm to the touch. 4. The veins in the ankle of one of the woman's legs are spider-like and purple.

3. These findings—swelling, redness, and warmth—indicate presence of a DVT. During the daily postpartum assessment, the nurse should assess for signs of thrombosis: pain, warmth, redness, and edema. The signs are usually unilateral. It is especially important for the nurse to refrain from palpating the calf too deeply because it is possible to dislodge a clot and cause a pulmonary embolism.

The nurse should suspect puerperal infection when a client exhibits which of the following? 1. Temperature of 100.2°F. 2. White blood cell count of 14,500 cells/mm3. 3. Diaphoresis during the night. 4. Malodorous lochial discharge.

4. A malodorous lochial flow is a common sign of a puerperal infection. "Puerperium" is another word for "postpartum." Although a client may have a slight temperature elevation, an elevated white blood cell count, and/or be diaphoretic, all three symptoms are normally seen in the postpartum client. The only finding that would make a nurse suspect infection is the malodorous lochial flow. The other findings are well within normal range for a postpartum woman.

A client, G1 P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for the nurse to perform for this postpartum client? 1. Strongly advise the client to breastfeed her baby. 2. Perform hourly incentive spirometer respiratory assessments. 3. Suggest that the nursery nurse feed the baby in the nursery. 4. Provide the client with supervised instruction on baby-care skills.

4. Providing instruction on baby-care skills is a very important action for the nurse to perform. TEST-TAKING TIP: Babies of mothers who are addicted to illicit drugs go through a withdrawal period and, because of the addiction, often have very disorganized behavior patterns. The nurse must provide guidance for the primipara regarding care of her difficult infant, especially because the client has already exhibited poor judgment. In addition, of course, the nurse must report the family to child protective services.

A client just delivered the placenta pictured below. The nurse will document that the woman delivered which of following placentas? 1. Circumvallate placenta. 2. Succenturiate placenta. 3. Placenta with velamentous cord insertion. 4. Battledore placenta.

4. The battledore placenta is characterized by an umbilical cord that is inserted on the periphery of the placenta. Clients with this type of placenta are at high risk for preterm problems like preterm labor and hemorrhage. TEST-TAKING TIP: There are a number of placental variations. The test taker should be familiar with each of the variations and high-risk nature of each.

A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? 1. Engorgement. 2. Mastitis. 3. Blocked milk duct. 4. Low milk supply.

4. The nurse would expect that the woman would have a low milk supply. The placenta produces the hormones of pregnancy, including estrogen and progesterone. When placental fragments are retained, those hormones are still being produced. Estrogen inhibits prolactin, which is the hormone of lactogenesis, or milk production. Women who have retained placental fragments, therefore, often complain of an insufficient milk supply for their babies.

A woman who wishes to breastfeed advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 1. Breast implants often contaminate the milk with toxins. 2. The glandular tissue of women who need implants is often deficient. 3. Babies often have difficulty latching to the nipples of women with breast implants. 4. Women who have implants are often able exclusively to breastfeed.

4. This information is true. Women who have had augmentation surgery usually are able to breastfeed exclusively . TEST-TAKING TIP: Because breast implants are usually inserted behind the breast tissue, the mammary ducts are rarely affected. Daily weights of babies whose mothers have had breast enlargements should be monitored as a precaution, but most of these mothers do produce sufficient quantities of breast milk.

A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take? Select all that apply. 1. Swaddle the baby in a baby blanket. 2. Discuss funeral options for the baby. 3. Encourage the couple to try to get pregnant again in the near future. 4. Ask the couple whether they would like to hold the baby. 5. Advise the couple that the baby's death was probably for the best.

1, 2, and 4 are correct. 1. This is an appropriate action. The baby should be handled with respect. 2. This is an appropriate action. Funerals help clients to achieve closure and to provide others with a means of acknowledging the baby's death. 4. This is an appropriate action. Although there are some clients who will decline to hold their babies, the action is very important for those who accept the opportunity. Clients must be encour- aged and assisted through the process of grieving and mourning their babies. In addition, as most women will remain on the obstetric unit, there must be a mecha- nism, like a specific picture placed on the woman's door, for communicating to every department in the hospital, from nursing to housekeeping to dietary, that the client has had a fetal death.

A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved? 1. Moderate lochia flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus above the umbilicus

1. A moderate lochia flow would indicate that the action was successful. Expected outcomes relate to specific nursing diagnoses that are devel- oped after making an assessment. This client's uterine muscle was boggy. The nursing action taken—massage—related directly to the nursing assessment—atonic uterus—and the outcome—normal lochia— indicated that the action was successful.

A woman is receiving Paxil (paroxetine) for postpartum depression. To prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following? 1. Alcohol. 2. Grapefruit. 3. Milk. 4. Cabbage

1. Clients should be warned about consuming alcohol when taking Paxil. Paxil is an antidepres- sant. Although the concurrent use of alcohol and Paxil has not been shown to adversely affect clients' abilities, it is advised that alcohol not be consumed while taking the medication. Some clients have actually reported that they experienced a craving for alcohol while taking the medication.

A postoperative cesarean client, who was diagnosed with severe preeclampsia in labor and delivery, is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question? 1. Methergine 2. Magnesium sulfate. 3. Advil (ibuprofen). 4. Morphine sulfate.

1. Methergine is contraindicated for this client. Methergine is an oxyto- cic agent. It acts directly on the myofibrils of the uterus. Secondarily, it also con- tracts the muscles of the vascular tree. As a result, clients' blood pressure tends to elevate when they receive this medication. Methergine should not be administered to a client whose blood pressure is 130/90 or higher.

Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

1. The client would be expected to complain of pain. A hematoma is a collection of blood under the skin. Although hematomas are usually simple bruises, large collections of blood can occur. Because the blood is trapped under the skin, the most common symptom is pain from the blood pressing on the pain sensors.

The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication? 1. Inhibit the mother's active immune response. 2. Aggressively destroy the Rh antibodies produced by the mother. 3. Prevent fetal cells from migrating throughout the mother's circulation. 4. Change the maternal blood type to Rh-positive.

1. The goal of the injection of RhoGAM is to inhibit the mother's immune response. When a client receives RhoGAM, she receives passive Rh anti- bodies. If any Rh antigen is circulating in the mother's bloodstream, the antibodies will destroy it. As a result, there will be no antigen in the mother's body to stimulate her mast cells to have an active antibody response. In essence, therefore, RhoGAM is injected to inhibit the client's immune response.

A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis.

1. This client is high risk for uterine atony. The uterus of a woman who delivers a macrosomic baby has been stretched beyond the usual pregnancy size. The muscle fibers of the myometrium, therefore, are stretched. After delivery the muscles are unable to contract effectively to stop the bleeding at the placental separation site.

. Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order? 1. Postpartum clients are at high risk for thrombus formation. 2. Post-cesarean clients are at high risk for fluid volume deficit. 3. Postpartum clients are at high risk for varicose vein development. 4. Post-cesarean clients are at high risk for poor milk ejection reflex.

1. This rationale is correct. Because of an elevation in clotting factors, all postpartum clients are at high risk for thrombus formation. The client in the scenario is post-cesarean section. The surgeon has ordered intermittent positive pressure boots for her because she is at high risk for thrombus formation and because she is on bed rest. Clients who deliver vaginally do not need the boots because they are able to ambulate immediately after delivery and, therefore, rarely experience pooling of blood in their extremities.

The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time? 1. Advise the woman to wash the area with soap to prevent mastitis. 2. Provide the woman with a tube of topical lanolin. 3. Remind the woman that the baby can become sick if he drinks the blood. 4. Get the woman an order for a topical anesthetic.

2. A small amount of lanolin should be applied to the nipple after each feeding. Using lanolin on the breasts is a type of moist wound healing. The lanolin is soothing and allows the nipple to heal without a scab developing on the surface of the nipple. Mothers are often very concerned about their babies swallowing the blood. Ingesting the blood does not adversely affect the babies unless, of course, the mother is HIV positive or carries another bloodborne virus.

A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following should be included in the patient teaching? 1. Take only ibuprofen for pain. 2. Avoid overeating dark green, leafy vegetables. 3. Drink grapefruit juice daily. 4. Report any decrease in urinary output.

2. This action is correct. Dark green, leafy vegetables contain vitamin K. The vitamin would decrease the anticoagu- lant affect of Coumadin. Patient education is essential when clients are discharged on powerful medications like Coumadin. The nurse must consider all aspects of the client's daily life, including diet (see above regarding dark green, leafy vegetables); herbs taken (some, such as ginkgo biloba, and ginger, can increase the action of the medication); activities (clients should avoid playing contact sports, using razors); and the like.

A breastfeeding woman calls the pediatric nurse with the following complaint: "I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time? 1. "Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes." 2. "Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula." 3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." 4. "In addition to giving the baby formula, you should wear a surgical face mask when you are around him."

3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." First, the baby has already been exposed to the mother and will continue being exposed to her even if she switches to formula. More important, however, is the fact that the mother will produce antibodies that will be consumed by the baby in the breast milk. The baby will, therefore, be more protected by continuing to breastfeed because formula contains no protective properties.

The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement? 1. Maintain client in left lateral recumbent position. 2. Teach sitz bath use on second postoperative day. 3. Perform active range-of-motion exercises until ambulating. 4. Assess central venous pressure during first postoperative day

3. Active range-of-motion exercises will help to prevent thrombus formation in post-cesarean patients. Clients, whether they have intermittent positive pressure boots ordered or not, should be advised to move their legs actively at least a few times each hour. If the client exercises, she will be much less likely to develop deep vein thrombosis.

A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery with complaints of burning on urination. 2. PP2 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO4 from cesarean delivery with complaints of firm and painful breasts.

3. This client should be assessed first. The hemoglobin level is well below normal. The nurse must recog- nize normal and abnormal findings. For example, 500 mL blood loss is an expected loss during a vaginal delivery. A hemoglo- bin of 7.2 g/dL, however, is well below the normal of 12 to 15 g/dL. This client is likely exhibiting signs of hypovolemia, including tachycardia, fatigue, and dizziness. She should be assessed first.

A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time? 1. "Monitor your blood glucose five times a day until your 6-week checkup." 2. "I will teach you how to inject insulin before you are discharged." 3. "Daily exercise will help to prevent you from becoming diabetic in the future." 4. "Your baby should be assessed every 6 months for signs of juvenile diabetes."

3. This is an appropriate statement to make. Women who develop gestational diabetes are high risk for developing type 2 diabetes. They should be encouraged to eat healthy foods and to exercise to prevent the onset of the chronic disease or, at the very least, to delay its onset.

The nurse is caring for a client, G3 P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make? 1. "Thank goodness. It could have been untreatable." 2. "I'm so happy that you have other children who are healthy." 3. "These things happen. They are the will of God." 4. "It is appropriate for you to cry at a time like this."

4. This statement is appropriate. Clients may need help or permission to express their grief. TEST-TAKING TIP: Nurses must be very careful how they speak with and care for clients who have had a baby that is less than perfect. Couples expect to birth perfect babies. When a baby who has a problem is born, the couple must grieve their "baby of fantasy," while they bond with and accept their "baby of reality."