Maternity(postpartum) nclex questions---saunders

1."Would you like to hold your baby?" Rationale: Nurses should explore measures that assist the family in creating memories of an infant so that the existence of the child is confirmed, and the parents can complete the grieving process. Asking the family if they would like to hold the baby meets this goal and demonstrates a caring and empathetic response. The remaining options are blocks to communication and devalue the parents' feelings.

17. A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, touching the baby. Which statement by the nurse should further assist the family in their initial period of grief? 1."Would you like to hold your baby?" 2."We need to take the baby from you now so that you can get some sleep." 3."Don't worry; there is nothing you could have done to prevent this from happening." 4."We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

Correct Answer: 1, 4 Rationale: After 24 hours, a sitz bath increases circulation and promotes healing. The sitz bath may circulate either cool or warm water over the perineum to cleanse the area and increase comfort. An ice pack is applied for the first 12 to 24 hours to reduce edema and bruising and numb the perineal area. The administration of oxytocin occurs after the third stage of labor to increase uterine contraction. Kegel exercises may be resumed immediately after birth but their purpose is to strengthen perineal muscles. The client is taught to do perineal care after each voiding or bowel movement to cleanse the area without trauma.

93. Which nursing actions should decrease the discomfort of an episiotomy? Select all that apply. 1.Performing sitz baths 2.Administering oxytocin 3.Encouraging Kegel exercises 4.Applying ice packs to the perineum for the first 12 to 24 hours 5.Teaching how to perform perineal care after each voiding or bowel movement

4. Prepare the client for surgery. Rationale: The information provided in the question indicates that the client is experiencing blood loss. Surgery would be indicated for this complication to stop the bleeding. Reassuring the client, applying perineal pressure, and monitoring the fundal height do not assist with controlling the bleeding in this emergency situation.

2. The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action? 1.Reassure the client. 2.Apply perineal pressure. 3.Monitor fundal height. 4.Prepare the client for surgery

4. An adolescent experiencing an emergency cesarean delivery for fetal distress . Rationale: Endometritis is an acute infection of the mucosal lining of the uterus that occurs immediately after delivery. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. Options 1, 2, and 3 do not describe the client "at risk" to develop endometritis following delivery.

72. The nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery? 1.A primigravida with a normal spontaneous vaginal delivery 2.A gravida II who delivered vaginally following an 18-hour labor 3.A woman experiencing an elective cesarean delivery at 38 weeks' gestation 4.An adolescent experiencing an emergency cesarean delivery for fetal distress

2. Encourage oral fluid intake. Rationale: During the first 24 hours following delivery, the mother's temperature may rise to 100° F (38° C) as a result of the dehydrating effects of labor. Therefore, the initial nursing action is to encourage fluid intake. The nurse should document the temperature, but this is not the initial action. Options 3 and 4 are not necessary at this time.

54. A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago. The mother's temperature is 100° F (38° C). What is the initial nursing action? 1.Document the finding. 2.Encourage oral fluid intake. 3.Administer acetaminophen. 4.Notify the primary health care provider.

1. " If I develop a fever, I will call my doctor." Rationale: The client should not lift anything heavier than the baby for 2 weeks. When getting out of bed, the client should turn on the side and push up with the arms. The client should call the doctor if a fever develops. Abdominal exercises should not be started following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision.

60. The nurse reinforces home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions? 1."If I develop a fever, I will call my doctor." 2."When getting out of bed, I should sit up straight." 3."I will lift nothing heavier than 30 pounds for 2 weeks." 4."I can start doing abdominal exercises as soon as I get home."

1. Vulva for a hematoma Rationale: Hematoma is suspected when the client reports pain or pressure in the vulvar area. Massive hemorrhage can occur into the tissues, resulting in hypovolemia and shock; therefore, the client's complaints must be checked so that interventions may begin immediately. The client's complaints are not related to options 2, 3, or 4.

57. The nurse is assessing a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints, the nurse should check which as a priority? 1.Vulva for a hematoma 2.Vagina for lacerations 3.Episiotomy for drainage 4.Rectum for hemorrhoids

4. Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's Rationale: Severe nipple soreness most often occurs as a result of poor positioning, incorrect latch-on, improper suck, or monilial infection. Comfort measures for nipple soreness include positioning the newborn with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's. Options 1, 2, and 3 do not identify measures that will alleviate the nipple soreness.

14. A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client? 1.Avoid rotating breastfeeding positions so that the nipple will toughen. 2.Stop nursing during the period of nipple soreness to allow the nipples to heal. 3.Nurse the newborn infant less frequently and substitute a bottle feeding until the nipples become less sore. 4.Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.

1. The finding is normal . Rationale: Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time the lochial flow should steadily decrease and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, the remaining options are incorrect.

15. The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding? 1.The finding is normal. 2.The finding indicates that the client is hemorrhaging. 3.The finding indicates the need to increase oral fluids. 4.The finding indicates the need to contact the primary health care provider (PHCP).

3. Obtain culture and sensitivity of lochia and urine. Rationale: Culture and sensitivity results should be obtained before any antibiotic therapy is administered to avoid masking the microorganisms identified in the culture. Administering an antibiotic and increasing fluid intake are standard parts of therapy for this type of infection but are not completed first. Although the client's temperature is monitored, reassessing the temperature in 30 minutes is not the first action; also, the data in the question indicate that the temperature has already been checked.

18. A second-day postpartum client diagnosed with a stable cardiac condition has scant lochia with a foul odor and a temperature of 102.2° F. The primary health care provider suspects infection and writes prescriptions to treat the client. Which prescription written by the primary health care provider should the nurse implement first? 1.Administer prescribed antibiotic. 2.Increase the intake of oral fluids. 3.Obtain culture and sensitivity of lochia and urine. 4.Reassess the client's temperature in 30 minutes.

Correct Answer: 1, 2, 3, 4 Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, wearing a supportive nonunderwire bra, maintaining a fluid intake of at least 3000 mL per day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs. Continued decompression of the breast by breastfeeding or breast pump is important to empty the breast and prevent the formation of an abscess.

3.The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1.Rest during the acute phase. 2.Wear a supportive, nonunderwire bra. 3.Maintain a fluid intake of at least 3000 mL. 4.Continue to breastfeed if the breasts are not too sore. 5.Take prescribed antibiotics until the soreness subsides. 6.Avoid decompression of the breasts by breastfeeding or breast pumping.

2. Administration of a subcutaneous rubella virus vaccine. Rationale: A blood sample for rubella titer is done on all women in the antepartum or postpartum period. A postpartum woman with a titer of 1.8 or less should receive a subcutaneous rubella virus vaccine (Meruvax II) following the birth of her baby. This stimulates active immunity against the rubella virus. The woman should be counseled to avoid pregnancy for 3 months after receiving the vaccine.

32. The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1.8. Which should the nurse anticipate to be prescribed by the primary health care provider? 1.A repeat rubella titer in 2 weeks 2.Administration of a subcutaneous rubella virus vaccine 3.Administration of a subcutaneous rubella virus vaccine for the newborn 4.Counseling to the mother and informing the mother that this is a normal titer

3. " I can start doing abdominal exercises as soon as I get home. " Rationale: Abdominal exercises should not start following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. Options 1, 2, and 4 reflect proper understanding of self-care after discharge.

36. The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching? 1."If I develop a fever, I will call my doctor." 2."I will lift nothing heavier than the baby for 2 weeks." 3."I can start doing abdominal exercises as soon as I get home." 4."When getting out of bed, I will turn on my side and push up with my arms."

2. " You can begin pumping as soon as possible after delivery with an electric breast pump. " Rationale: Prematurity usually causes a delay before the baby can be fed at the breast. Mothers must initiate and maintain their milk supply with an electric breast pump. Milk expression by electric pump needs to begin as soon as possible after delivery and be done 8 or more times each 24 hours. Hand expression is not as effective as using an electric pump.

37. A postpartum client who delivered at 32 weeks of gestation would like to breastfeed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother? 1."You need to pump your breasts every 6 hours to establish a good milk supply." 2."You can begin pumping as soon as possible after delivery with an electric breast pump." 3."You can prepare your breast by pinching and rolling the nipples and hand-expressing colostrum." 4."There is no need to prepare for breastfeeding now because the infant is receiving tube feedings."

4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp. Rationale: Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn to grasp the nipple. Option 1 is appropriate advice for mothers experiencing inverted nipples. True inverted nipples will retract if the areola is pressed between the thumb and forefinger, making option 2 incorrect. Option 3 will only make the mother cold and has no effect on inverted nipples.

44.A new mother is attempting to breastfeed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breastfeeding the newborn? 1.Massage the breast, applying gentle pressure on the areola. 2.Have the mother grasp the nipples between the thumb and forefinger and tug firmly to get the nipple to protrude. 3.Have the mother take a cool shower, allowing the water to run over the breasts because this will encourage the nipples to protrude. 4.Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.

4. Keep the client and her family members informed of her progress. Rationale: Keeping the client and her family informed about her condition will help minimize fear and apprehension. Maintaining strict bed rest, monitoring vital signs, and performing fundal massage every 2 hours address physiological needs

5. The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action? 1.Maintain strict bed rest. 2.Monitor the vital signs every 2 hours. 3.Perform firm fundal massage every 2 hours. 4.Keep the client and her family members informed of her progress.

3. The bright red bleeding is abnormal and should be reported. Rationale: Lochial flow should be distinguished from bleeding originating from a laceration or episiotomy, which is usually brighter red than lochia, and presents as a continuous trickle of bleeding even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported. Options 1, 2, and 4 are incorrect interpretations of the assessment data.

50. The postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Which determination should the nurse make based on this information? 1.This is a normal expectation following episiotomy. 2.The mother should be allowed bathroom privileges only. 3.The bright red bleeding is abnormal and should be reported. 4.The perineal assessment should be performed more frequently.

2. Begin feeding on the less sore nipple. Rationale: The nurse should instruct the mother to begin feeding on the less sore nipple. The infant sucks with greater force at the beginning of feeding. Rotating breastfeeding positions, breaking suction with the little finger, nursing frequently, not allowing the newborn to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple are also measures to alleviate nipple soreness. The mother should be encouraged to continue breastfeeding to maintain adequate milk supply while nipples toughen and adapt to feedings.

51. A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client? 1.Stop nursing until the nipples heal. 2.Begin feeding on the less sore nipple. 3.Avoid rotating breastfeeding positions. 4.Substitute a bottle-feeding until the nipples heal.

4. " I will massage the breasts before feeding to stimulate let-down." Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive well-fitting bra at all times, breastfeeding frequently, taking a warm shower just before feeding or applying warm compresses, and alternating the breasts during feeding.

52. The nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures? 1."I will avoid wearing a bra." 2."I won't breastfeed during the nighttime hours." 3."I will take a cool shower just before I breastfeed." 4."I will massage the breasts before feeding to stimulate let-down."

Correct Answer: 1, 3, 4 Rationale: Signs of placental separation include lengthening of the umbilical cord, change in shape from discoid to globular, sudden gush of dark blood from the introitus and visualization of fetal membranes at the introitus. Immediately after delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 fingerbreadths below it and in the midline of the abdomen. If the fundus is more than 1 cm above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage.

53. A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterus to determine if the placenta has detached. Which findings indicate to the nurse that placental detachment has occurred? Select all that apply. 1.Lengthening of the umbilical cord 2.Change in shape from globular to discoid 3.Sudden gush of dark blood from the vagina 4.Appearance of fetal membranes at the introitus 5.Change in position of fundus to level of 4 to 6 cm above the umbilicus

1. " I can resume sexual activity at any time. " Rationale: It is recommended that the woman refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped. This process usually takes about 3 weeks. Lochia is bright red for about 3 days postpartum and then changes to brownish pink discharge (from days 4 to 10), then white (from days 11 to 14). Walking is an excellent form of exercise in the immediate postpartum period because it is not strenuous and maintains circulation. An adequate intake of fluid (2000 mL daily) is important to prevent dehydration and constipation.

55. The nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching? 1."I can resume sexual activity at any time." 2."I can expect red drainage for a few days." 3."Walking is an excellent form of exercise for me now." 4."I should drink an adequate amount of fluids every day."

Correct Answer: 2,3, 4 Rationale: Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and would experience sleep disturbances.

56. The nurse is monitoring a new mother for signs of postpartum depression. Which observations in the mother indicate the need for further data collection related to this form of depression? Select all that apply. 1.Sleeps well through the night 2.Shows a lack of interest in eating 3.Lacks the ability to concentrate on tasks 4.Complains of feeling tired all of the time 5.Shows enthusiasm to care for her newborn

2. Request to hold the infant following delivery. Rationale: The nurse should explain to the parents the expected events following delivery of the fetus and should tell the parents that they can hold their infant following delivery. Viewing and holding the dead infant can alleviate any negative images the mother or her partner may have. Providing a picture or other mementos will help preserve the memory of the infant. If the parents refuse a picture, most hospitals will keep a picture and copy of the footprints on file for parents to access later. Parents should be encouraged to verbalize their feelings, ask questions about the process, and make their own decisions about care as much as possible.

59. A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response? 1.State they have no questions 2.Request to hold the infant following delivery 3.Refuse a footprint and picture of the infant to take home 4.Are surprised by the appearance of the infant following delivery

4. Have the mother place the infant in the bassinet and assist the mother in dressing the baby. Rationale: The infant needs to be placed in the bassinet for safety. The mother needs to be reassured that she can safely care for her infant, and the nurse should assist the mother in dressing the baby. Option 2 is incorrect because the infant needs to be placed in the bassinet for safety. Options 1 and 3 are incorrect because these actions do not address the mother's needs. Option 4 is the only option that focuses on the mother's feelings and needs and the safety of the infant.

61. The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, which nursing action is the most appropriate? 1.Place the infant back in the bassinet. 2.Diaper the infant while he is lying on the bed. 3.Place the infant in the bassinet and take the baby back to the nursery. 4.Have the mother place the infant in the bassinet and assist the mother in dressing the baby.

4. Risk of ineffective bonding between the mother and newborn. Rationale: There is a period shortly after birth that is uniquely important to attachment and mother-infant bonding. Option 4 identifies the problem that could exist if the client is unable to have the newborn infant present in the room. Inability to cope, isolating self from others and denying the presence of an infection do not relate to the information provided in the question.

63. A postpartum client suspected of having an infection is informed that she will be unable to have the newborn present in the room with her. The nurse plans care, knowing that which problem is the highest priority at this time? 1.Inability to cope 2.Need to isolate self from others 3.Denial that an infection is present 4.Risk of ineffective bonding between the mother and newborn

3."You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus." Rationale: The client is at risk for developing gestational diabetes with each pregnancy. She also has an increased risk of developing overt diabetes and needs to comply with follow-up appointments. She needs to be taught techniques to lower her risk for developing diabetes, such as weight control. The diagnosis of gestational diabetes indicates that this client has an increased risk for developing overt diabetes; however, with proper care it may not develop.

64. A postpartum client diagnosed with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse should make which response to the client? 1."Your blood glucose level is within normal limits now, so you will be all right." 2."You will only have to worry about the diabetes if you become pregnant again." 3."You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus." 4."Once you have gestational diabetes, you have overt diabetes and must be treated with medication for the rest of your life."

4. Lack of knowledge regarding ability to care for the newborn. Rationale: Lack of knowledge regarding ability to care for the newborn implies a lack of information or psychomotor skills concerning a condition or treatment. This problem best describes the situation presented in the question. Grieving in a dysfunctional way implies prolonged unresolved grief leading to detrimental activities. Lack of ability to cope implies that the person is unable to manage stressors adequately. Lack of self-esteem with regard to caring for the newborn represents temporary negative feelings about oneself in response to an event.

65. In formulating the plan of care, which problem is most important to address for a postpartum client who has expressed concerns about not knowing how to care for her newborn? 1.Lack of ability to cope 2.Presence of grieving in a dysfunctional way 3.Lack of self-esteem with regard to caring for the newborn 4.Lack of knowledge regarding ability to care for the newborn

2. Her temperature is 99 F Rationale: By definition, a postpartum infection is present when the temperature is greater than 100.4° F on 2 or more successive days, not counting the first 24 hours after birth. Temperatures of this magnitude must be considered a sign of a postpartum infection unless proven otherwise. Therefore, a temperature of 99° F does not warrant notification of the primary health care provider. The woman needs to contact the primary health care provider if the temperature rises above 100.4° F. The other signs listed should be reported as stated.

66. When the client has been given instructions about postoperative complications following cesarean delivery, the nurse interprets that the client requires clarification of the information when the client identifies which situation as a reason to notify her primary health care provider? 1.Painful urination occurs. 2.Her temperature is 99° F. 3.Redness at the incision site is present. 4.Flow that is heavier than a normal period occurs.

1. Provide support to the mother. Rationale: After a precipitate delivery, the woman may need help processing what has happened and time to assimilate what has happened. The mother may be exhausted, in pain, stunned by the rapid nature of the delivery, or simply following cultural norms. Providing support to the mother is the most therapeutic action by the nurse. It is important to encourage the mother to hold the baby and asking the mother about support systems, but not immediately after a precipitate delivery. The mother should not be left alone at this time.

67. A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How should the nurse be most therapeutic in this situation? 1.Provide support to the mother. 2.Give the mother some time alone. 3.Ask the mother about support systems. 4.Encourage the mother to hold the baby.

2. Collect data regarding how the client perceived the event. Rationale: As a result of anesthesia, anxiety, and the experience of a sudden catastrophic event, the client may well have experienced a decreased ability to take in and process information. The nurse should first identify the client's perception of the event before deciding how to intervene. Having time to interact with the infant may be helpful but not as a first step. The remaining options are not helpful because they are not therapeutic, or they deal with subjects the client may not be ready to face

68. A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should take which approach as the first step to support the client psychologically? 1.Avoid talking about the dead fetus. 2.Collect data regarding how the client perceived the event. 3.Ask the client and husband about plans for future pregnancies. 4.Suggest that family members see and hold the dead infant if they wish.

2. Weigh the perineal pad before and after use. Rationale: The most accurate method for determining the amount of lochial flow is to weigh the perineal pads before and after use. Once these two weights are noted, the amount of lochial flow can be accurately determined. Each gram increase in the weight is roughly equivalent to 1 mL of blood loss. To obtain an accurate estimate of lochial flow, the time between pad changes is a factor that must also be incorporated into the analysis. The remaining options are incorrect.

70. A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Which activity should the nurse implement as part of the method to accurately determine the amount of flow for documentation purposes? 1.Count the number of pads used each day. 2.Weigh the perineal pad before and after use. 3.Estimate the extent of staining on a perineal pad. 4.Track the number of times a day the pad is changed.

3. Encouraging the client to take pain medication as prescribed. Rationale: Keeping the client comfortable by appropriately using prescribed analgesics will facilitate her interest in caring for the infant. Nursing responsibilities for the care of a client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day) and promoting bed rest in Fowler's position to facilitate drainage and lessen congestion. The correct option is the only nursing intervention that demonstrates the nurse's understanding of both the physiological and psychosocial needs of the postpartum client experiencing endometritis.

71. The nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the client's participation in infant care? 1.Limiting fluid intake to keep the bladder empty 2.Promoting family members to care for the infant 3.Encouraging the client to take pain medication as prescribed 4.Maintaining the client in a supine position whenever possible

1. Abdominal tenderness and chills Rationale: Signs/symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications such as infections of the fallopian tubes, ovaries, and blood (sepsis). Options 2, 3, and 4 represent normal maternal physiological responses in the immediate postpartum period. These changes represent the normal adaptation of reproductive organs (involution) and maternal physiological responses because of the decreased hormonal levels and fluid losses that occur during labor.

73. The nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery supports this diagnosis? 1.Abdominal tenderness and chills 2.Increased perspiration and appetite 3.Maternal oral temperature of 101.2° F 4.A firm uterus two fingerbreadths below midline

3. She should alternately contract and relax the muscles of the perineal area. Rationale: Kegel exercises are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple, with progression to increasingly strenuous exercises. Women who maintain the perineal muscle tone may benefit in later life by the development of less stress urinary incontinence.

74. As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client indicates that the client understands the instructions? 1.Strenuous exercises should be avoided for at least 6 months. 2.Exercise should be postponed for 4 weeks to allow healing time. 3.She should alternately contract and relax the muscles of the perineal area. 4.The use of postpartum exercises can eliminate stress urinary incontinence.

3. Encourage her to hold the infant even when the infant is crying. Rationale: Holding the infant close and allowing the infant to feel the warmth initiates a positive experience for the mother and consoles the infant. The use of a high-pitched voice and participating in infant care are additional methods of promoting parent-infant attachment. Infants should not be allowed to sleep in the parental bed. The parents require time alone as a couple. Additionally, the danger of suffocation of the infant exists if the infant is allowed to sleep between the parents.

76. The nurse is adding to a plan of care for a postpartum client. Which intervention should promote parent-infant bonding? 1.Support her decision to have the infant sleep in the parental bed. 2.Have the nursing staff care for the infant when she is frustrated. 3.Encourage her to hold the infant even when the infant is crying. 4.Suggest using a low-pitched voice to provide comfort to the infant.

3. Covering her with a warm blanket Rationale: In the postpartum period, a woman may commonly experience a shaking and uncontrollable chill immediately after birth. The exact cause of this occurrence is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The best nursing action is to provide a warm blanket to the client and a warm drink if this is not contraindicated. It is not necessary to contact the primary health care provider. Massaging the fundus and placing the client in the Trendelenburg's position have no effect on the client's condition.

78. A client arrives to the postpartum unit following the delivery of her newborn premature infant. On data collection, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate? 1.Gently massaging her fundus 2.Contacting her health provider care 3.Covering her with a warm blanket 4.Placing her in the Trendelenburg's position

4. " A sitz bath will promote healing of the perineum. " Rationale: Warm, moist heat provided by a sitz bath is used 24 hours after tissue trauma from a vaginal birth to provide comfort and promote healing and reduce the incidence of infection. Ice is used in the first 24 hours to reduce edema and numb the tissue in the perineal area. Promoting a bowel movement is best achieved by ambulation. Thrombophlebitis prevention is not related to a sitz bath.

80. A postpartum nurse reinforces information provided to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client makes which statement? 1."A sitz bath will numb my perineal tissue." 2."A sitz bath will stimulate a bowel movement." 3."A sitz bath will help minimize thrombophlebitis" 4."A sitz bath will promote healing of the perineum."

1. " Tell me about the delivery of your baby. " Rationale: It is important for the mother to think of the procedure as the birth of the baby. The mother may become disappointed because she was unable to deliver vaginally, complicating the postpartum phase. Option 2 brings the surgery to focus and can inhibit the mother from bonding with the neonate. Options 3 and 4 place the focus on the future, and the mother needs to focus on the birth of the baby.

81 . The nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement provides the best encouragement? 1."Tell me about the delivery of your baby." 2."The surgical birth of your baby went very well." 3."You will be able to have other children vaginally." 4."The surgery will not limit you in having more pregnancies."

3. Fewer muscle fibers in the lower segment of the uterus will result in poor contractions. Rationale: In placenta previa, the placenta is in the lower segment of the uterus near or over the internal cervical os. After delivery, the muscle tissue in that segment has fewer muscle fibers and the weak contractions cannot compress the open vessels at the site. Infection is a high risk because the placenta site is located near the vagina, and any vaginal organisms can easily travel to the uterus, causing infection. Options 1, 2, and 4 are incorrect.

83. The nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage. The nurse plans care based on which information related to the condition? 1.It will cause increased uterine contractions postdelivery. 2.Increased vaginal secretions will prevent the site from healing properly. 3.Fewer muscle fibers in the lower segment of the uterus will result in poor contractions. 4.Sexual intercourse before 6 weeks postpartum will significantly increase the risk for infection.

3. " I should alternately contract and relax the muscles of the perineal area." Rationale: Kegel exercises (alternately contracting and relaxing the muscles of the perineal area) are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple, with progression to increasingly strenuous exercises. Women who maintain the perineal muscle tone may benefit in later life by the development of less stress urinary incontinence.

84. The nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she makes which statement? 1."Strenuous exercises should be started while in the hospital." 2."Exercise should be delayed for 4 weeks to allow healing time." 3."I should alternately contract and relax the muscles of the perineal area." 4."The use of postpartum exercises can result in stress urinary incontinence."

4. " I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115 F. " Rationale: Following episiotomy, the client should be instructed in measures to decrease discomfort and perineal swelling. Ice decreases circulation, promotes vasoconstriction, reduces edema, and promotes a local anesthetic effect. Local anesthetic sprays reduce discomfort. Gluteal muscle tightening reduces direct pressure on the perineum, so discomfort is minimized. Heat from sitz baths increases circulation to the perineum, thereby promoting oxygenation and healing, which reduces discomfort. However, the water temperature should not be any greater than 100° F to 105° F.

89. The nurse is reinforcing instructions to a client who had an episiotomy during the birthing process. Which statement by the client indicates a need for further teaching? 1."I can apply ice to the area." 2."I can apply a local anesthetic spray to the area." 3."I should tighten the perineum before I sit and then relax it slowly after being seated." 4."I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115° F."

4 . Assist the client to the bathroom to void and then reassess the fundus. Rationale: A full bladder causes the uterus to be displaced above the umbilicus and well to one side of the abdominal midline. After voiding, if the fundus is boggy, it can be massaged, but this is not the first action. The woman should be assisted to the bathroom to void and then the fundus should be reassessed. Turning the client to her left side will not bring the fundus to midline. This is not a normal finding; the fundus should be firm at the umbilicus or 1 fingerbreadth below the umbilicus 6 hours after delivery.

91. The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first? 1.Massage the fundus. 2.Turn the client to her left side. 3.Document the findings; this is normal. 4.Assist the client to the bathroom to void and then reassess the fundus.

3. Experiencing a severe reaction to prior administered human globulin. Rationale: Rho(D) immune globulin is not administered if a client has experienced a severe reaction to its component, human globulin. Rho(D) immune globulin is indicated when Rh-negative clients are exposed to Rh-positive fetal blood cells in any way, including abortion and amniocentesis. This medication is made from human plasma (a consideration if the woman is a member of the Jehovah's Witness denomination). Additionally, there is a risk of transmitting infectious agents, including viruses, when this medication is administered.

96. Rho(D) immune globulin is prescribed for a client after delivery of a full-term infant. Before administering the medication, the nurse reviews the client's history, recognizing which circumstance as a contraindication for administering this medication? 1.Exposure to Rh sensitization because of abortion procedure 2.Exposure to Rh sensitization during a scheduled amniocentesis 3.Experiencing a severe reaction to prior administered human globulin 4.Possibility that Rh-positive fetal blood cells have entered the circulation of an Rh-negative woman

4. Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours. Rationale: During the immediate postpartum period, vital signs are taken every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. Vital signs are monitored thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

98. The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals? 1.Every hour for the first 2 hours and then every 4 hours 2.Every 30 minutes during the first hour and then every hour for the next 2 hours 3.Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4.Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours

3. The bright red bleeding is abnormal and should be reported. Rationale: Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported. Therefore, the other options are incorrect interpretations.

7. After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make? 1.This is a normal expectation after episiotomy. 2.The mother should be allowed bathroom privileges only. 3.The bright red bleeding is abnormal and should be reported. 4.The perineal assessment should be performed more frequently.

1. This may be a sign of hemorrhage or shock. Rationale: A pulse range of 50 to 70 beats per minute is normal in a mother following delivery and may occur for the first 1 to 2 days after delivery. A weak and thready or rapid pulse is abnormal and may be a sign of hemorrhage or shock. Particular attention should be paid to the pulse rate when there has been a blood loss of 500 mL or greater during or after delivery. Options 2, 3, and 4 are incorrect interpretations.

88 . The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding should indicate which accurate interpretation to the nurse? 1.This may be a sign of hemorrhage or shock. 2.This is a normal pulse rate following delivery. 3.The mother is very excited about the delivery of the birth. 4.This is a normal pulse rate following a loss of 500 mL of blood.

4. To complete the entire antibiotic regimen . Rationale: If antibiotics are prescribed, the client must complete the regimen even though symptoms will be reduced in 24 to 48 hours. Options 1, 2, and 3 are inappropriate treatment measures for mastitis. The client should breastfeed, wear a supportive bra, and take analgesics as prescribed.

43. The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client? 1.To stop breastfeeding 2.To avoid wearing a bra 3.To avoid taking analgesics 4.To complete the entire antibiotic regimen

4. " My left breast is sore, so I will offer only my right breast frequently for breastfeeding. "

20. The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching? 1."I will wash my breasts gently with plain water." 2."I need to change my breast pads when they are wet." 3."When my breasts feel engorged, I will use a heat pack for the pain." 4."My left breast is sore, so I will offer only my right breast frequently for breastfeeding."

1."I don't need birth control because I will be breastfeeding." Rationale: Amenorrhea may occur during breastfeeding, but the client can still ovulate without menstruating. The caloric intake should be increased by 200 to 500 cal/day (per PHCP's prescription), and the diet should include additional fluids and prenatal vitamins, as prescribed. The use of soap on the breasts is avoided because it tends to remove natural oils, which can lead to cracked nipples.

4. A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? 1."I don't need birth control because I will be breastfeeding." 2."I need to increase my caloric intake by 500 calories a day." 3."I shouldn't use soap to wash my breasts because I will be breastfeeding." 4."I need to be sure that I increase my fluid intake and take my prenatal vitamins while breastfeeding."

4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day. Rationale:Involution is the progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately 1 fingerbreadth or 1 cm per day. The other options do not accurately describe involution.

8. The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? 1.The inverted uterus returning to normal 2.The gradual reversal of the uterine muscle into the abdominal cavity 3.The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4.The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

3. The client is required to stay on bed rest. Rationale: Clients with thrombophlebitis may be placed on bed rest with elevation of the affected extremity. Bed rest restricts normal newborn care, feeding, and parenting and will require interventions that promote attachment. Options 1, 2, and 4 are unrelated to the subject of the question.

40. A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation? 1.The client is unable to nurse the baby. 2.The client is an older first-time mother. 3.The client is required to stay on bed rest. 4.The client is considering giving the baby up for adoption.

1. Washes and dries her hands before feeding. Rationale: Hepatitis B virus (HBV) is highly contagious by direct contact with blood and body fluids of infected persons. Strict hand washing before contact with the newborn will assist in prevention of the transmission of infection. Option 2 will not affect disease transmission. Options 3 and 4 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B.

26. The nurse has reinforced instructions to a postpartum client who is hepatitis B positive on how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure? 1.Washes and dries her hands before feeding 2.Requests that the window be closed before feeding 3.Holds the infant properly during feeding and burping 4.Tests the temperature of the formula before initiating feeding

2. Bladder distention Rationale: Immediately following expulsion of the placenta, the fundus is firmly contracted, midline, and located one half to two thirds of the way between the symphysis pubis and the umbilicus. Because the uterine ligaments are still stretched, a full bladder can move the uterus upward and to the side. Options 1, 3, and 4 are complications not usually indicated by a firm and displaced uterus.

45. The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which condition? 1.Uterine atony 2.Bladder distention 3.Endometrial infection 4.Retained placental fragments

1. A

58. It has been 12 hours since a client's delivery of a newborn. The nurse assesses the mother for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? Refer to figure.View Figure 1.A 2.B 3.C 4.D

1. " You will need to bottle-feed your newborn." Rationale: Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breastfeeding. Clients who have HIV are advised not to breastfeed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

1. The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1."You will need to bottle-feed your newborn." 2."You will need to feed your newborn by nasogastric tube feeding." 3."You will be able to breastfeed for 6 months and then will need to switch to bottle-feeding." 4."You will be able to breastfeed for 9 months and then will need to switch to bottle-feeding."

2. At the level of the umbilicus Rationale: After delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 fingerbreadths below it and in the midline of the abdomen. If the fundus is 4 cm above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. If the fundus is noted to the right of the abdomen, it may indicate a full bladder. By about 10 days postpartum, the uterus will be in the symphysis pubis area.

10. After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note? 1.To the right of the abdomen 2.At the level of the umbilicus 3.About 4 cm above the level of the umbilicus 4.One fingerbreadth above the symphysis pubis

1. Dyspnea, tachypnea, and tachycardia Rationale: Pulmonary embolism is the passage of a thrombus into the lungs. The usual signs and symptoms are dyspnea, tachypnea, tachycardia, a congested cough (not a dry cough), hemoptysis (not hematemesis), pleuritic chest pain, and a feeling of impending doom. Back pain, edema, skin tenderness, hematemesis, and increased skin temperature are not associated with pulmonary embolism.

21. The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms? 1.Dyspnea, tachypnea, and tachycardia 2.Dry cough, shortness of breath, and back pain 3.Edema, skin tenderness, and increased skin temperature 4.Hematemesis, chest pain, and a feeling of impending doom

1. Changes in vital signs Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Options 3 and 4 are inaccurate for a client who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely to indicate the presence of a hematoma.

22. The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma? 1.Changes in vital signs 2.Signs of heavy bruising 3.Complaints of a tearing sensation 4.Complaints of lower abdominal discomfort

1. " I do not feel any urges yet to empty my bladder." Rationale: The fourth stage of labor is the period of time from 1 to 4 hours after delivery, when the woman's body begins to readjust and relax. An epidural may lead to loss of bladder sensation and resulting rapid bladder filling. The remaining options relate to earlier stages in the labor process.

23. The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which statement by the mother is most likely to occur at this time related to her birth experience? 1."I do not feel any urges yet to empty my bladder." 2."I feel very anxious about my childbirth experience." 3."I am experiencing a lot of pain and feel the need to push." 4."I am very tired from the physical exertion I experienced during labor."

2. The presence of infection Rationale: Lochia, the discharge present after birth, is red the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor similar to the odor of menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids and ambulate are not accurate interpretations related to the assessment finding.

30. The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which? 1.A normal finding 2.The presence of infection 3.The need for increasing oral fluids 4.The need for increasing ambulation

Correct Answer: 2, 4, 5 Rationale: The treatment for thrombophlebitis is anticoagulant therapy. Adverse effects of anticoagulants include bleeding and would be recognized by the presence of epistaxsis, hematuria, and ecchymosis. Dysuria may indicate a bladder infection. Headache is not an adverse effect of an anticoagulant.

41. The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms? Select all that apply. 1.Dysuria 2.Epistaxis 3.Headache 4.Hematuria 5.Ecchymosis

3. Check the uterine fundus and lochia. Rationale: A potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted, and vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours to maintain physiological integrity. Options 1, 2, and 4 are nursing actions that would follow.

46. The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is most important for the nurse to take at this time? 1.Assist the client with breastfeeding. 2.Encourage food and fluid intake. 3.Check the uterine fundus and lochia. 4.Provide privacy for the parents and their newborn.

2. Pain, redness , or swelling in the breasts. Rationale: Signs of infection include pain, redness, heat, and swelling of a localized area of the breast. If these signs/symptoms occur, the client needs to contact the primary health care provider. Uterine cramping while breastfeeding, diaphoresing at night, and having serosanguineous discharge are normal changes that occur in the postpartum period.

77. The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the primary health care provider? 1.Uterine cramping while breastfeeding 2.Pain, redness, or swelling in the breasts 3.Diaphoresis that occurs during the night 4.Existence of a serosanguineous vaginal drainage

1. Encourage oral fluids. Rationale: Temperatures up to 100.4° F (38° C) in a mother during the first 24 hours after birth are often related to the dehydrating effects of labor. Increasing hydration by encouraging oral fluids will help bring the temperature to a normal reading. Administering acetaminophen, immediately notifying the RN or primary health care provider or removing blankets and reassessing the temperature are unnecessary actions at this time.

87. The nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action is appropriate? 1.Encourage oral fluids. 2.Administer acetaminophen. 3.Immediately notify the registered nurse or primary health care provider. 4.Remove the blankets from the mother, and recheck her temperature in 30 minutes.

3. " I should avoid wearing a bra at this time. " Rationale: Wearing a bra or applying a breast binder applies pressure, which reduces congestion and discomfort. Ice packs reduce circulation and thus congestion and also provide an anesthetic effect. Analgesics help relieve the pain.

90. The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching? 1."I should apply ice packs to the breasts." 2."I can take analgesics for the discomfort." 3."I should avoid wearing a bra at this time." 4."I should wear a breast binder while my breasts are engorged."

3. 500 calories per day. Rationale: If the mother is breastfeeding, her calorie needs increase by approximately 500 calories per day. The mother should also be instructed regarding the need for increased fluids and the need for prenatal vitamins and iron supplements.

101. The nurse is providing nutritional counseling to a new mother who is breastfeeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount? 1.100 calories per day 2.300 calories per day 3.500 calories per day 4.1000 calories per day

4. " I need to isolate my infant for 48 hours after starting the antibiotics." Rationale: Broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take them as prescribed. Analgesics often are necessary, and warm compresses or sitz baths may be used to provide comfort. The infant is not routinely isolated from the mother with a wound infection, but the mother must be taught how to protect the infant from contact with contaminated articles.

107 . The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse reinforces instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further teaching? 1."I need to take the antibiotics as prescribed." 2."I need to take warm sitz baths to promote healing." 3."I need to apply warm compresses to provide comfort." 4."I need to isolate my infant for 48 hours after starting the antibiotics."

3. Absence of fever Rationale: Fever is the first indication of an infection. An absence of fever indicates that the goal stated in the question has been met. Chills, abdominal tenderness, and loss of appetite indicate the presence of an infection.

62. A postpartum client is at high risk for infection. A goal has been developed that states, "The client will not develop an infection during her hospital stay." Which data support that the goal has been met? 1.Loss of appetite 2.Presence of chills 3.Absence of fever 4.Abdominal tenderness

Correct Answer: 1, 3 Rationale: Following delivery of the placenta, the maternal cardiac system begins to make several normal changes, leading to slowing of the pulse rate and an elevation in blood pressure. The client should be alert and oriented.

86 . The nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse should document which expected changes? Select all that apply. 1.Slowed pulse rate 2.Increased pulse rate 3.Elevated blood pressure 4.Decreased blood pressure 5.Altered level of consciousness

4. Postpartum hemorrhage Rationale: The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding. The client is not at greater risk for postpartum infection, coagulopathy, or chronic hypertension with this disorder.

69. The nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication? 1.Coagulopathy 2.Postpartum infection 3.Chronic hypertension 4.Postpartum hemorrhage

Correct Answer: 1, 2, 4, 6 Rationale: Clinical signs/symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea.

95.The nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in the neonate? Select all that apply. 1.Tremors 2.Irritability 3.Bradycardia 4.Hypertension 5.Flaccid muscles 6.Exaggerated startle reflex

Correct Answer: 1, 2, 4,5 Rationale: The action of oxytocin is to stimulate the uterus to contract, which includes controlling uterine atony and augmenting labor contractions. In addition, oxytocin aids in the milk let-down reflex. Oxytocin does not minimize the possibility of uterine infection.

82. Oxytocin is utilized in multiple ways in the labor and delivery unit. The nurse correctly identifies which purposes for administering this medication? Select all that apply. 1.Aids milk let down 2.Controls uterine atony 3.Minimizes uterine infection 4.Augments labor contractions 5.Stimulates uterine contractions

2. " I will change the perineum pads three times a day." Rationale: Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineum area to prevent infection. The mother also should be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The mother also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.

102. The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching? 1."I will take warm sitz baths three times a day." 2."I will change the perineum pads three times a day." 3."I will wipe my perineum from front to back after voiding and defecation." 4."I will use warm water or an irrigation device to rinse the perineum after elimination."

4. Prepare to administer oxygen at 8 to 10 L by tight face mask. Rationale: If pulmonary embolism is suspected, oxygen should be administered at 8 to 10 L by tight face mask. Oxygen is used to decrease hypoxia. The woman also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this action is not the initial nursing action. An IV line also will be required, but this action should follow the administration of the oxygen.

105. A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1.Check the client's blood pressure. 2.Prepare to administer morphine sulfate. 3.Prepare for the insertion of an intravenous (IV) line. 4.Prepare to administer oxygen at 8 to 10 L by tight face mask.

3. An increase in the pulse rate from 88 to 102 beats per minute Rationale: During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure is not the earliest sign of hemorrhage. An elevation in temperature is not a sign of excessive blood loss. Although the respiratory rate may increase, this is not an early sign of hemorrhage. In addition, an increase in the respiratory rate from 18 to 22 breaths per minute is not significant.

103. The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood loss and shock? 1.A temperature of 100.4° F 2.A blood pressure change from 130/88 to 124/80 mm Hg 3.An increase in the pulse rate from 88 to 102 beats per minute 4.An increase in the respiratory rate from 18 to 22 breaths per minute

Correct Answer: 1, 4 Rationale: Rh incompatibility occurs when an Rh-negative mother is sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman carries and delivers a fetus who is Rh positive. During pregnancy and delivery, some of the baby's Rh-positive blood can enter the maternal circulation. The woman's immune system then forms antibodies against Rh-positive blood, which can be detected in the indirect Coombs' test. Administration of RhoGAM blocks this response by providing passive antibody protection against the Rh antigen. If both the mother and father are Rh negative, the infant cannot be Rh positive.

108. The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who has delivered an infant. Which criteria need to be met in order to administer this medication? Select all that apply. 1.Rh negative mother 2.Rh negative infant 3.Rh negative father 4.Negative Coombs' test 5.Negative serum AFP test

4. Postpartum hemorrhage Rationale: Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The nurse monitors the client frequently for signs of postpartum hemorrhage. Options 1, 2, and 3 are not directly associated with placenta previa.

24. The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing? 1.Coagulopathy 2.Postpartum infection 3.Chronic hypertension 4.Postpartum hemorrhage

3. Notify the registered nurse(RN) Rationale: Normally a few small clots may occur in the first 1 to 2 days after birth from pooling of the blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of such clots, such as uterine atony or retained placental fragments, must be determined and treated to prevent further blood loss. Although the findings should be documented, the most appropriate action is to notify the RN. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be an appropriate action in this situation.

100. When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which nursing action is appropriate? 1.Document the findings. 2.Reassess the client in 2 hours. 3.Notify the registered nurse (RN). 4.Encourage increased oral intake of fluids.

3. "Breastfeed from the left breast and gently pump the right breast." Rationale: In most cases, the mother can continue to breastfeed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breasts, breastfeeding should be discontinued and a pump used to empty the breast (but the milk should be discarded). The remaining statements are incorrect options.

16. A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breastfeed her infant. Which should the nurse tell the client? 1."Pump both breasts and discard the milk." 2."The infant should be bottle-fed temporarily." 3."Breastfeed from the left breast and gently pump the right breast." 4."Stop breastfeeding from both breasts until this condition resolves."

2. The mother constantly complains of tiredness and fatigue. Rationale: Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and experience sleep disturbances.

34. Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression? 1.The mother is caring for the infant in a loving manner. 2.The mother constantly complains of tiredness and fatigue. 3.The mother demonstrates an interest in the surroundings. 4.The mother looks forward to visits from the father of the newborn.

Correct Answer: 1, 2, 5 Rationale: Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the lower extremity improves venous return and may be recommended. Warm packs may be applied to the affected area to promote healing. Anticoagulants or anti-inflammatory agents are not needed unless the condition persists. After 5 to 7 days of bed rest, and when signs/symptoms disappear, the woman may gradually begin to ambulate.

35. The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions are included in the plan of care? Select all that apply. 1.Maintaining bed rest 2.Elevating the affected extremity 3.Administering anticoagulants daily 4.Administering anti-inflammatory agents every 4 hours 5.Applying warm compresses to the affected area as prescribed

4. Administer anticoagulants as prescribed. Rationale: The purpose of anticoagulant therapy is to prevent the clot from moving to another area. Options 1, 2, and 3 will not prevent pulmonary embolism.

42. he goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action? 1.Check heart rate every hour. 2.Check respirations every hour. 3.Check blood pressure every hour. 4.Administer anticoagulants as prescribed.

4. Gather data from the client and spouse about the perception of the event. Rationale: The most appropriate initial intervention in planning to meet the emotional needs of the client and her spouse is to gather data about the perception of the event. Although options 1, 2, and 3 are likely to be a components of the plan of care, the initial intervention is to assess the perception of the event.

97. The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate? 1.Allow family members to name the baby. 2.Allow the client and the spouse to hold the baby. 3.Encourage the client to talk about the dead fetus. 4.Gather data from the client and spouse about the perception of the event.

2. Ask the client to urinate and empty her bladder. Rationale: Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When fundal assessment is performed, the woman is asked to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, in which case it should be massaged gently until firm.

99. The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1.Ask the client to turn onto her side. 2.Ask the client to urinate and empty her bladder. 3.Massage the fundus gently before determining the level of the fundus. 4.Ask the client to lie flat on her back with her knees and legs flat and straight.

4. Notify the registered nurse(RN), who will then contact the primary health care provider(PHCP). Rationale: During the first 24 hours postpartum, the mother's temperature may be elevated as a result of dehydration. However, if the temperature is more than 2° F above normal, this may indicate infection, and the PHCP will need to be notified. Applying cool packs to the abdomen is an inappropriate action, and, additionally, this action requires a prescription. The remaining options may be a component of care but are not the most appropriate based on the data in the question.

11. The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action? 1.Apply cool packs to the abdomen. 2.Continue to monitor the temperature. 3.Remove the blanket from the client's bed. 4.Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).

3. " It will help prevent bleeding and control bleeding if it occurs. " Rationale: Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used in the postpartum period to stimulate the uterus to contract and prevent or control postpartum hemorrhage. Options 1, 2, and 4 are incorrect actions of the medication.

28. The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration? 1."It will help relax the muscles of my uterus." 2."It will help relieve the nausea I'm experiencing." 3."It will help prevent bleeding and control bleeding if it occurs." 4."It will help me produce more milk for breastfeeding."

4. " My afterpains are really strong." Rationale: Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used postpartally to stimulate the uterus to contract and control excessive blood loss. The client statements in options 1, 2, and 3 are not related to this medication.

47. The nurse is assigned to care for a client who received methylergonovine maleate in the immediate postpartum period. The nurse determines the medication is effective when the client makes which statement? 1."I feel less nauseated." 2."The pain is less intense." 3."At least now I can sleep." 4."My afterpains are really strong."

4. " Foods and fluids that will increase urine alkalinity should be consumed." Rationale: The woman with a urinary tract infection should be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. The woman must be encouraged to take the medication for the entire time it is prescribed. Foods and fluids that acidify the urine need to be encouraged.

104. On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse reinforces instructions to the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further teaching? 1."I should urinate frequently throughout the day." 2."My prescribed medication must be taken until it is completed." 3."My fluid intake should be increased to at least 3000 mL daily." 4."Foods and fluids that will increase urine alkalinity should be consumed."

3. " The infection can occur at any time during breastfeeding." Rationale: Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breastfeeding. It is more common in mothers nursing for the first time and usually affects one breast at a time but can affect both breasts. Constriction of the breasts from a bra that is too tight may interfere with emptying of all the ducts and may lead to infection.

106. A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate? 1."The infection usually involves both breasts." 2."The infection can occur at any time during breastfeeding." 3."The infection usually is caused by wearing a supportive bra." 4."The infection is most common for women who have breast-fed in the past."

1. Ambulate frequently. Rationale:Stasis is believed to be a major predisposing factor for the development of thrombophlebitis. Because cesarean delivery poses a risk factor, the client should ambulate early and frequently to promote circulation and prevent stasis. Wearing support stockings, applying warm, moist packs to the legs and maintaining bed rest with legs elevated are implemented if thrombophlebitis occurs.

12. The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action? 1.Ambulate frequently. 2.Wear support stockings. 3.Apply warm, moist packs to the legs. 4.Remain on bed rest, with the legs elevated.

4. This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy. Rationale: A low transverse uterine incision is unlikely to rupture during a subsequent labor and is the only type of uterine incision considered safe for a subsequent VBAC delivery. It cannot be extended laterally because of the location of the major uterine blood vessels in the lower uterine segment. In the presence of a placenta previa, a classic incision into the body of the uterus would be needed to prevent incising into the placental area. A suprapubic skin incision can be made with a lower uterine transverse incision.

25. An elective cesarean delivery is being planned for a pregnant client. The nurse is reviewing the plans for the surgery with the client. A low transverse uterine incision will be used. The client asks the nurse to explain why this approach is being used. The nurse's response is based on which premise? 1.This approach requires that a vertical skin incision be made. 2.This type of incision allows for extension if a larger incision is needed. 3.This approach is the best choice with a placenta previa on the lower anterior uterine wall. 4.This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.

4. The spouse lacks hope because of the loss of the baby and illness of his wife. Rationale: A person who lacks hope experiences hopelessness and sees no way out of the situation except for death. There are no data in the question that support the situation of grieving, deficient knowledge, or anxiety

27. The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation? 1.The spouse is grieving because of the loss of the baby. 2.The spouse is anxious about the reason the baby died. 3.The spouse does not have any knowledge about the disease process. 4.The spouse lacks hope because of the loss of the baby and illness of his wife.

3. Instruct the mother to request help when getting out of bed. Rationale: Orthostatic hypotension may occur during the first 8 hours after birth. Feelings of faintness and dizziness are signs that caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times getting out of bed. Option 1 is not a helpful action and could cause increased dizziness. Option 2 requires a primary health care provider's prescription. Option 4 is unnecessary.

31. The nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate? 1.Elevate the head of the bed. 2.Obtain a hemoglobin and hematocrit level. 3.Instruct the mother to request help when getting out of bed. 4.Inform the nursery room nurse to avoid bringing the newborn to the mother until the feelings of lightheadedness and dizziness have subsided.

1. A positive nurse-client relationship. Rationale: The nurse-client relationship is most significant. Option 4 is the opposite of what needs to happen. Brief separation decreases the chance of correct latch and suck in the immediate postpartum period. Infants should be placed at the breast immediately after delivery. Previous breastfeeding experience and a primary health care provider who encourages clients to breastfeed are not the most significant factors.

38. The nurse is assisting in developing a plan of care for a client preparing to breastfeed. In planning care, which factor is most significant in teaching a client to breastfeed? 1.A positive nurse-client relationship 2.A client with previous breastfeeding experience 3.A primary health care provider that encourages clients to breastfeed 4.Brief separation of the infant and mother after birth to allow the mother to rest

4. " The only medications that I will take are prenatal vitamins and stool softeners. " Rationale: After surgical evacuation and repair of a vaginal hematoma, the client will need an antibiotic because she is at increased risk for infection because of the break in skin integrity and collection of blood at the hematoma site. The client statements in options 1, 2, and 3 indicate that the client understands the necessary home care measures.

39. After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement? 1."I will probably need my mother to help me with housekeeping." 2."Because I am so sore, I will nurse the baby while lying on my side." 3."My husband and I will not have intercourse until the stitches are healed." 4."The only medications that I will take are prenatal vitamins and stool softeners."

Correct Answer: 4, 5 Rationale: Retained placental fragments and infections are the primary causes of subinvolution. When either of these factors is present, the uterus has difficulty contracting. The conditions in the remaining options are not associated causes of subinvolution.

48. A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence? Select all that apply. 1.High estrogen levels 2.Maternal hypertension 3.Elevated progesterone levels 4.Retained placental fragments 5.Maternal reproductive tract infections

Correct Answer: 1, 2, 4 Rationale: Midline episiotomies are effective, easily repaired, and generally result in less pain. The blood loss is greater and the repair is more difficult and painful with the mediolateral episiotomy than the midline episiotomy. A midline episiotomy may extend more readily with a difficult delivery than the mediolateral episiotomy. This midline episiotomy is no more likely to become infected than another type of episiotomy.

85. A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which findings? Select all that apply. 1.Less pain 2.Less blood loss 3.More difficult repair 4.More likely to extend with birth of LGA infant 5.More likely to become infected than other types of episiotomies

1. Red Rationale: The color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days. The color of the lochia then changes to a pinkish-brown and occurs from day 4 to 10 postpartum. Finally, the lochia changes to a creamy white color that occurs from day 10 to 14 postpartum.

6. The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note? 1.Red 2.Pink 3.White 4.Serosanguineous

Correct Answer: 2, 3, 5 Rationale: Signs/symptoms of an intrauterine fetal demise include absence of fetal movement, absent fetal heart tones and no change or a decrease in fundal height. Many signs/symptoms of pregnancy may diminish, such as uterine size and breast size and tenderness. Option 1 is associated with preeclampsia or may be a normal finding. Greater than expected fundal height can be a result of twins, an LGA baby, or incorrect dates.

75. The nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which signs/symptoms should the nurse expect to note when collecting data on the client? Select all that apply. 1.Proteinuria 2.Absence of fetal movement 3.Fetal heart tones not audible 4.Fundal height greater than expected for gestational age 5.Prenatal record indicating no change in fundal height for several weeks

1. " Breastfeeding is allowed once the baby has been vaccinated." Rationale: Although HBV is transmitted in breast milk, once the first dose of hepatitis B vaccine and the serum immune globulin have been administered to the newborn, the woman may breastfeed without risk to the newborn. Options 2, 3, and 4 are incorrect responses.

92. A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client? 1."Breastfeeding is allowed once the baby has been vaccinated." 2."You will not be able to breastfeed the baby until 6 months after delivery." 3."Breastfeeding is not advised, and you should seriously consider bottle-feeding the baby." 4."Breastfeeding is not a problem, and you will be able to breastfeed immediately after delivery."

2. " I am having a dark red discharge." Rationale: In assessment of the perineum, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is a dark red. Options 1, 3, and 4 are not the expected characteristics of lochia at this time.

49. The postpartum nurse is collecting data from a client who delivered a viable newborn 2 hours ago. Which statement does the nurse anticipate that the client will make regarding her lochial flow? 1."My discharge is white." 2."I am having a dark red discharge." 3."My lochia has already turned pink." 4."My lochia appears to be light red and liquidy."

4. Massage the breasts before feeding to stimulate let-down. Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive and well-fitting bra at all times, taking a warm shower or applying warm compresses just before feeding, and alternating breasts during feeding.

9. A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement? 1.Breastfeed only during the daytime hours. 2.Apply cold compresses to the breast before feeding. 3.Avoid the use of a bra while the breasts are engorged. 4.Massage the breasts before feeding to stimulate let-down.

3. Prepare a heat pack for application to the area. Rationale: The application of ice will reduce the swelling caused by hematoma formation in the vulvar area. Checking the vital signs and performing fundal massage every 4 hours and preparing a heat pack for the perineal area will not reduce swelling.

13. The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action? 1.Check vital signs every 4 hours. 2.Measure the fundal height every 4 hours. 3.Prepare a heat pack for application to the area. 4.Prepare an ice pack for application to the area.

2. Checks the calf areas for redness or swelling. Rationale: Redness, swelling, and pain in the calf area are signs of thrombophlebitis, a potential complication in the postpartum period. Options 1 and 4 do not determine the presence of thrombophlebitis. Although the client with thrombophlebitis may experience pain when ambulating, option 3 is not the best intervention from those provided in the options.

79. The nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs? 1.Palpates for pedal pulses 2.Checks the calf areas for redness or swelling 3.Checks for the presence of pain when ambulating 4.Observes for the presence of a vaginal hematoma

2. Adhesions Rationale: In newborn males, the prepuce is continuous with the epidermis of the glans and is nonretractable. Forced retraction may cause adhesions to develop. Separation should be allowed to occur naturally, which will take place between 3 years and 5 years of age. Most foreskins are retractable by 3 years of age and should be pushed back gently for cleaning once a week.

94. The parents of a neonate who is not circumcised asks the nurse why the foreskin should not be retracted. The nurse explains that retracting the foreskin should be avoided because which complication may occur? 1.Pain 2.Adhesions 3.Increased risk of infection 4.Engorgement of the penis head

2. Uterine contractions. Rationale: Oxytocin stimulates uterine contractions and is administered to reduce the incidence of hemorrhage after expulsion of the placenta. It does not directly affect urinary output or milk production. The subsequent contraction of the uterus may cause an increase in the afterbirth pains.

29. Oxytocin is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication? 1.Milk production 2.Uterine contractions 3.Increased urinary output 4.Decreased afterbirth pains

Correct Answer: 1, 4, 5 Rationale: Mastitis is an infection frequently associated with a break in the skin surface of the nipple. Measures to reduce the possibility of mastitis include changing breast pads frequently, avoiding the use of soap on the nipples, and exposing the nipples to the air to dry. Breastfeeding no more often than every 4 hours is too long a time period not to nurse and wearing an underwire bra may lead to the development of milk stasis and mastitis.

19. In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply. 1.Change breast pads frequently. 2.Breastfeed infant every 4 hours. 3.Wear an underwire bra for support. 4.Avoid the use of soap on your nipples. 5.Intermittently expose your nipples to the air.

4. Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped. Rationale: It is recommended that the woman refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped. This process usually takes about 3 weeks. Options 1, 2, and 3 are inaccurate.

33. A postpartum client asks the nurse when she may resume sexual activity. Which response should the nurse give to the client? 1.Sexual activity may be resumed at any time. 2.Sexual activity may be resumed after a normal menstrual period begins. 3.Sexual activity should not be resumed until the 8-week checkup with the primary health care provider. 4.Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped.