PostPartum Saunders

44. The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider? 1. White blood cells, 12,500 cells/mm3. 2. Red blood cells, 4,500,000 cells/mm3. 3. Hematocrit, 26%. 4. Hemoglobin, 11 g/dL

3. Hematocrit, 26%

48. The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

2. "I understand but I still would like you to try to urinate."

70. A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h × 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

3. Blood pressure The blood pressure may elevate, therefore, to danger- ous levels. The medication should be held if the blood pressure is 130/90 or higher

28. The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

1. Apply an ice pack to the perineum.

59. Which of the following nursing interventions would be appropriate for the nurse to perform to achieve the client care goal: The client will not develop postpartum thrombophlebitis? 1. Encourage early ambulation. 2. Promote oral fluid intake. 3. Massage the legs of the client twice daily. 4. Provide the client with high-fiber foods.

1. Encourage early ambulation. To prevent clot formation, clients should ambulate as soon as possible after delivery. If they must be bed bound because of complica- tions, the nurse should contact the physician for an order for antiembolic stockings and/or antiembolic pressure boots and have the client perform active range-of-motion exercises.

71. Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink ice tea with lemon or lime.

1. Lie prone with a small pillow cushioning her abdomen.

87. During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/symptoms? Select all that apply. 1. Pain. 2. Warmth. 3. Discharge. 4. Ecchymosis. 5. Redness.

1. Pain. 2. Warmth. 5. Redness.

56. Which of the following is the priority nursing action during the immediate postpartum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

1. Palpate fundus. Fundal assessment is the priority nurs- ing action.

86. A nurse is performing a postpartum assessment on a newly delivered client. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

1. Palpate the breasts. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum. The nurse should palpate the breasts to assess for fullness and/or engorgement. The best way to remem- ber the items in the postpartum assessment is to remember the acronym BUBBLEHE. The letters stand for: B—breasts; U—uterus; B—bladder; B—bowels and rectum (for hemorrhoids); L—lochia; E—episiotomy; H—Homan's sign; and E—emotional status.

57. Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in the Trendelenburg position. 3. Notify the primary health care provider. 4. Increase the intravenous infusion.

1. Provide the woman with warm blankets. The shaking is very common and, unless accompanied by a fever, is of no physio- logical concern. The best action by the nurse is supportive—providing the client with a warm blanket and reassuring her that the response is within normal limits.

69. An Asian client's temperature 10 hours after delivery is 100.2°F, but when encour- aged she refuses to drink her ice water. Which of the following nursing actions is most appropriate? 1. Replace the ice water with hot water. 2. Notify the client's health care provider. 3. Reassess the temperature in one half hour. 4. Remind the client that drinking is very important.

1. Replace the ice water with hot water.

34. A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? 1. Respiratory rate 8 rpm. 2. Complaint of thirst. 3. Urinary output of 250 mL/hr. 4. Numbness of feet and ankles.

1. Respiratory rate 8 rpm.

55. During a postpartum assessment, it is noted that a G1 P1001 woman, who delivered vaginally over an intact perineum, has a cluster of hemorrhoids. Which of the following would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure.

1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 5. The client should apply topical anesthetic as a relief measure.

"325. The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

1. The diet should include additional fluids. "The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

76. A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

2. "Your stitches are actually far away from your rectal area." Unless they have a third- or fourth-degree laceration, they should be assured that the stitches are a distance away from the rectal area.

4. To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with povidone-iodine after toileting.

2. Change the peripad at each voiding. The clients should void about every 2 hours, but this action is not an infection control measure.

26. A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2. Fundus. Because her uterus has been stretched so many times, she is at high risk for uterine atony during the postpartum period. The nurse must, therefore, moni- tor the postpartum contraction of her uterus very carefully.

24. During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.

2. Lochia alba. The normal progression of lochial change is as follows: lochia rubra, days 1 to 3; lochia serosa, days 3 to 10; and lochia alba, days 10 until discharge stops.

"326. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

2. Massage the fundus until it is firm. "If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

64. A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

2. Postpartum blues last about a week or two.

6. A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

2. She feeds her baby every 2 to 3 hours.

58. One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.

2. The client will have a stable white blood cell count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. The WBC is elevated during late pregnancy, delivery, and early postpartum, but if it rises very rapidly, the rise is often associated with a bacterial infection. The lochia usually smells "musty." When a client has endometritis, however, the lochia smells "foul." A temperature above 100.4°F after the first 24 hours postpartum is indicative of a puerperal infection.

42. A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

2. The nurse stabilizes the base of the uterus with his or her dependent hand. If the base of the uterus is not stabilized during the assessment, there is a possibility that the uterus may invert or prolapse. While stabilizing the base, the nurse should gently assess for the fundus by palpating the abdomen with the flat part of the fingers until the fun- dus is felt.

15. A breastfeeding woman, 11/2 months postdelivery, calls the nurse in the obstetrician's office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection reflex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk.

2. The same hormone stimulates orgasms and the milk ejection reflex.

20. Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit, 39%. 2. White blood cell count, 16,000 cells/mm3. 3. Red blood cell count, 5 million cells/mm3. 4. Hemoglobin, 15 grams/dL.

2. White blood cell count, 16,000 cells/mm3. The red blood cell count is often low in postpartum clients. The hemoglobin is often low in postpar- tum clients.

38. The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2. Well-approximated edges.

18. The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3. Decreased blood volume. During pregnancy, the blood volume increased by almost 50%. Once the placenta is delivered, the client no longer needs the added blood volume. Immediately after delivery, therefore, the woman experiences marked diuresis and diaphoresis as the blood volume drops

27. The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.

3. Have her turn and deep breathe every 2 hours.

"329. The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3. Heavy 4. Excessive " Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

3. Heavy

66. The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terri- ble. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Post-trauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

3. Ineffective individual coping related to hormonal shifts.

25. The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong: "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.

3. Inform the client that polyuria is normal. This client's physical assessment is normal. If the client's bladder were distended, the client's fundus would be elevated in the abdomen and the client would have excess blood loss. It is unneces- sary, therefore, either to catheterize the woman or to measure her output. Polyuria is normal because the client no longer needs the large blood volume she produced during her pregnancy.

19. A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Notify the neonate's pediatrician.

3. Reassure the woman that this is normal. Because the client's blood volume is returning to its nonpreg- nant level, the client loses fluids via both the kidneys and through insensible loss. As a result, postpartum women often awake from sleep with their nightwear saturated with perspiration.

79. A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant? 1. Assess client's fundal height. 2. Teach client how to massage her fundus. 3. Take the client's vital signs. 4. Document quantity of lochia in the chart.

3. Take the client's vital signs.

40. The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on third postpartum day. 2. Administer analgesics every four hours per doctor's orders. 3. Teach client to contract her buttocks before sitting. 4. Irrigate incision twice daily with antibiotic solution.

3. Teach client to contract her buttocks before sitting.

78. A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

3. The client will have a moderate lochial flow. When establishing priorities, the test taker should consider the client's most important physiological functions—that is, the C-A-B —circulation, airway, and breathing. If the client were to bleed heavily, her circulation would be compromised. None of the other goals is directly related to the C-A-Bs.

39. A client, G1 P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."

4. "To have things work out differently than you had planned is disappointing."

23. The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

4. Fundus 3 cm below the umbilicus, lochia serosa.

41. A client, G1 P1001, 1 hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

4. Assist the woman to the bathroom. Because they have elevated clotting factors, postpartum clients are at high risk for thrombus formation. When they need to urinate, they should be encouraged to ambulate to the bathroom to prevent pooling of blood. Clients should be accompanied to the bathroom, however, because they may be light-headed from the stress and work of labor and delivery.

11. A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottle feed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

4. Discuss the action of breastfeeding hormones. It is inappropriate to advise a breastfeed- ing mother to switch to the bottle unless there is a specific medical reason for her to do so. Massaging the fundus will not relieve the client's discomfort. An alternate position will not relieve the client's discomfort.

"320. The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

4. Increase hydration by encouraging oral fluids." "The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

37. A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes.

4. Pad saturation every 30 minutes. This blood loss is excessive, especially for a postoperative cesarean section client. The surgeon should be notified.

"327. The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

4. The client with lochia that is red and has a foul-smelling odor." "Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

43. A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections.

1. Assure the woman that frequent urination is normal after delivery. Frequent urination is normal after a delivery. The urine of a postpartum client will be blood tinged. This does not mean that the client has red blood cells in her urine, but rather that the lochia from the vagina has con- taminated the sample. Unless a catheter- ized sample is obtained, it is virtually impossible to obtain an uncontaminated urine sample in the postpartum period.

8. A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider.

4. Notify the woman's primary health care provider. Heavy lochia is not a normal finding. Moderate lochia, which is similar in quantity to a heavy menstrual period, is a normal finding. The woman's fundus is firm. There is no need to massage the fundus. The fundus is at the umbilicus and it is firm. It is unlikely that her bladder is full.

"324. The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement(s)? Select all that apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." "5. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply."6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily." "The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"322. The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within 2 weeks postpartum" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

1. 3 days postpartum "After birth, the nurse should auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

"323. The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume" Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

1. Client pain level "The priority nursing consideration for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

49. A client, G1 P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary health care provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

2. Massage the woman's fundus. When a postpartum client's bladder is distended, the uterus becomes displaced and boggy. The client should be escorted to the bathroom to void; the lochia flow should also be assessed. However, before escorting the client to urinate, the nurse should gently massage the uterus.

73. The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

2. Prolactin. Because the hormones of pregnancy produced by the placenta—progesterone and estro- gen—drop precipitously at this time, prolactin is no longer inhibited and, therefore, rises. The way the woman intends to feed her baby is irrelevant.

"321. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

3. Instruct the client to request help when getting out of bed. "Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

80. A client, G2 P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.

3. Lower both of her legs at the same time.

47. The nurse is examining a 2-day-postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

3. Normal involution, lochia rubra moderate. The nurse would expect the fundus to descend below the umbilicus approximately 1 cm per postpartum day. In other words, 1 day postpartum, the fundus is usually felt 1 cm below the umbilicus; 2 days postpartum, it is usually felt 2 cm below the umbilicus, and so on.

63. A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

3. Normal postpartum behavior.

"328. When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider. 4. Encourage increased oral intake of fluids." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

3. Notify the health care provider. " Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation." Excerpt From: Linda Anne Silvestri. "Saunders Comprehensive Review for the NCLEX-RN® Examination." iBooks.

3. A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.

4. It is likely that this client is dehydrated. She should be advised to drink fluids. In the early postpartum period, up to 24 hours after delivery, the most common reason for clients to have slight temperature elevations is dehydra- tion. During labor, clients work very hard, often utilizing breathing techniques as a form of pain control. As a result, the clients lose fluids through insensible loss via the respiratory system.

75. The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1 P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6 ̊F, 82, 18; fundus firm at umbilicus; moderate lochia rubra; ambulated to bathroom to void 4 times; breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? 1. Fluid volume deficit r/t excess blood loss. 2. Impaired skin integrity r/t vaginal delivery. 3. Impaired urinary elimination r/t excess output. 4. Knowledge deficit r/t lack of parenting experience.

4. Knowledge deficit r/t lack of parenting experience. This client is a primigravida. The nurse would anticipate that she is in need of teaching regarding newborn care as well as self-care.