Saunders OB Practice Questions for Exam 1

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client has 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

1. Client pain level

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

2. Massage the fundus until it is firm

The nurse is monitoring a PP client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1. Changes in vital signs

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temp of 100.4F 2. An increase in the pulse rate from 88-102 bpm 3. A blood pressure change from 130/88 to 124/80 mmHg 4. An increase in the respiratory rate from 18 to 22 breaths/minute

2. An increase in the pulse rate from 88-102 bpm

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?

3 days postpartum

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of calf 2. Coolness of the calf 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3. Enlarged, hardened veins

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

3. Heavy

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 HOB 2. Obtain Hgb and Hct 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

3. Instruct the client to request help when getting out of bed.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial action? 1. Record findings 2. Massage the fundus 3. Notify the HCP 4. Place the client in Trendelenburg's position

3. Notify the HCP

The nurse is developing a plan of care for a PP client with a small vulvar hemoatoma. The nurse should include which specific action during he first 12 hours after delivery? 1. Assess vitals every 4 hours 2. Measure fundal height every 4 hours 3. Prepare an ice pack for application to the area 4. Inform the HCP of assessment findings

33. Prepare an ice pack for application to the area

On assessment of a pp client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. elevate the client's legs 2. document the findings 3. massage fundus until it's firm 4. push on uterus to assist in expressing clots

33. massage fundus until it's firm

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had eipudural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

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. The initial nursing action would be which of the following? 1. Initiate an IV line 2. Assess the client's blood pressure 3. Prepare to administer morphine sulfate 4. Administer oxygen, 8 to 10L/minute, by face mask

4. Administer oxygen, 8 to 10L/minute, by face mask

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn,. Which client statement would indicate a need for further instruction? 1. I should breastfeed every 2-3 hours 2. I should change breast pads frequently 3. I should wash my hands well before breastfeeding 4. I should wash my nipples daily with soap and water.

4. I should wash my nipples daily with soap and water.

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 findings 2. Retake the temp in 15 minutes 3. Notify the HCP 4. Increase hydration by encouraging oral fluids

4. Increase hydration by encouraging oral fluids.

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild after-pains 2. The client with a pulse rate of 60bpm 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor

4. The client with lochia that is red and has a foul-smelling odor

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 statements. 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

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 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

1. The diet should include additional fluids

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

1. Wear a supportive bra 2. Rest during the acute phase 3. Maintain a fluid intake of at least 3000mL 4. Continue to breast-feed if the breasts are not too sore

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring Hgb and Hct levels

2. Encouraging fluid intake

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 1cm. Which nursing action is most appropriate? 1. Document the findings 2. Reassess the client in 2 hours 3. Notify the HCP 4. Encourage increase oral intake of fluids

3. Notify the HCP