Chapter #'s 13-16 & 21-22 PrepU Questions

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh? A. 3,500 g to 4000 g B. 4,000 g to 4500 g C. 3,000 g to 3500 g D. 2500 to 3000 g

B. 4,000 g to 4500 g

A 39-week-gestation client presents to the labor and birth unit reporting abdominal pain. What should the nurse do first? A. Ask if this is the client's first pregnancy. B. Determine if the client is in true or false labor. C. Notify the healthcare provider. D. Assess to see if the client has any drug allergies.

B. Determine if the client is in true or false labor.

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding? A. Dilation (dilatation) of cervix B. Bloody show C. Engagement of fetus D. Rupture of amniotic membranes

A. Dilation (dilatation) of cervix

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? A. administering bromocriptine B. restricting fluids C. applying ice D. applying warm compresses

C. applying ice

As a woman enters the second stage of labor, her membranes spontaneously rupture. When this occurs, what would the nurse do next? A. Assess fetal heart rate for fetal safety. B. Elevate her hips to prevent cord prolapse. C. Test a sample of amniotic fluid for protein. D. Ask her to bear down with the next contraction.

A. Assess fetal heart rate for fetal safety.

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth? A. low Apgar B. increased agitation C. decreased alertness D. increased crying

C. decreased alertness

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? A. Assess the woman's fundus. B. Initiate Ringer's lactate infusion. C. Assess the woman's vital signs. D. Call the woman's health care provider.

A. Assess the woman's fundus.

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax? A. Anxiety can slow down labor and decrease oxygen to the fetus. B. Decreased anxiety will increase trust in the nurse. C. Anxiety will increase blood pressure, increasing risk with an epidural. D. Increased anxiety will increase the risk for needing anesthesia.

A. Anxiety can slow down labor and decrease oxygen to the fetus.

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning? A. increased heart rate B. increased hematocrit level C. increased blood pressure D. increased cardiac output

A. increased heart rate

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? A. 1000 mL B. 500 mL C. 250 mL D. 750 mL

A. 1000 mL

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority? A. Assign a female nurse to care for her. B. Ensure that the newborn's daily bath is performed by the nurses. C. Provide time for prayers to be performed at the bedside. D. Allow time for the numerous visitors who come to see the woman and newborn.

A. Assign a female nurse to care for her.

A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize? A. Depressed deep tendon reflexes B. Bradycardia C. Tachypnea D. Elevated blood glucose

A. Depressed deep tendon reflexes

A nurse is providing discharge instructions to a postpartum client. Which symptom is a possible complication that the nurse should educate the client about? A. Notify the health care provider of increased lochia and bright red bleeding. B. Palpate your fundus to make sure it is soft. C. Notify the health care provider of a decrease in the amount of brown-red lochia. D. Notify the health care provider of passing clots the size of golf balls.

A. Notify the health care provider of increased lochia and bright red bleeding.

A 29-week-gestation client is admitted with moderate vaginal discharge. The nurse performs a nitrazine test to determine if the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What should the nurse do next? A. Notify the health care provider. B. Prepare the client for birth. C. Assess the client's cervical status. D. Perform Leopold's maneuver.

A. Notify the health care provider.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. How should the nurse respond? A. Pierced nipple B. Frequent feeding C. Complete emptying of the breast D. Use of breast pumps

A. Pierced nipple

The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: A. left lower quadrant. B. right lower quadrant. C. left upper quadrant. D. right upper quadrant.

A. left lower quadrant.

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. A. loss of confidence B. manifestations of mania C. decreased interest in life D. inability to concentrate E. bizarre behavior

A. loss of confidence C. decreased interest in life D. inability to concentrate

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? A. "Are you in any pain with your bleeding?" B. "How much blood was on the two pads?" C. "What time did you last change your pad?" D. "When did you last void?"

B. "How much blood was on the two pads?"

Which nursing action is a priority when the fetus is at the +4 station? A. Prepare for an immediate cesarean section B. Have a blue bulb suction and an infant warmer ready C. Provide lubricating jelly and an internal monitor D. Have a tocometer and a patient gown ready

B. Have a blue bulb suction and an infant warmer ready

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? A. Check and inspect the lochia, and document all findings. B. Have the client void, and then massage the fundus until it is firm. C. Notify the primary care provider, and document the findings. D. Assess a full set of vital signs.

B. Have the client void, and then massage the fundus until it is firm.

Which is the most important nursing assessment of the mother during the fourth stage of labor? A. Heart rate B. Hemorrhage C. Blood pressure D. The mother's psyche

B. Hemorrhage

The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist? A. Urinary retention B. Inability to push C. Dry, cracked lips D. Rapid progress of labor

B. Inability to push

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation? A. Increase the methotrexate. B. Turn off the oxytocin. C. Turn off the methotrexate. D. Increase the oxytocin.

B. Turn off the oxytocin.

At what time is the laboring client encouraged to push? A. When the fetal head can be seen B. When the cervix is fully dilated C. When the nurse wants the client to push D. When the health care provider has arrived

B. When the cervix is fully dilated

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia? A. delayed hemorrhage B. bladder distention C. uterine atony D. extreme diaphoresis

B. bladder distention

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except? A. the client will show no signs of infection. B. maintain previous household routines to prevent infection. C. discuss methods that the woman will use to prevent infection. D. list signs of infection that she will report to her health care provider.

B. maintain previous household routines to prevent infection.

Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client? A. aspiration B. placental separation C. amniotic fluid embolism D. congestive heart failure

C. amniotic fluid embolism

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? A. "I'll contact your health care provider." B. "I'll check on you in a few hours." C. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." D. "If you don't attempt to void, I'll need to catheterize you."

C. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize? A. "This is not normal unless you are in active labor; come to the hospital and be checked." B. "That is something we expect with a second or third baby, but because it is your first, you need to be checked." C. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." D. "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital."

C. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."

The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 g/dl (140 g/L) and hematocrit of 42% (0.42). Which result should the nurse prioritize? A. Hemoglobin 12 g/dl (120 g/L) and hematocrit 38% (0.38) in a woman who has given birth vaginally B. Hemoglobin 13 g/dl (130 g/L) and hematocrit 40% (0.40) in a woman who has given birth vaginally C. Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean D. Hemoglobin 11 g/dl (110 g/L) and hematocrit 34% (0.34) in a woman who has given birth by cesarean

C. Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters? A. Determining chest and head circumference B. Checking for identifying birthmarks or skin injuries C. Inspecting posture, color, and respiratory effort D. Auscultating bowel sounds, and measuring urine output

C. Inspecting posture, color, and respiratory effort

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints? A. Try to avoid carrying the baby for a few days. B. Apply ice to the sore joints. C. Maintain correct posture and positioning. D. Soak in a warm bath several times a day.

C. Maintain correct posture and positioning.

The nurse reviews the history of a postpartum woman, G3, P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client? A. metritis B. postpartum hemorrhage C. deep venous thrombosis D. uterine atony

C. deep venous thrombosis

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as? A. acupressure. B. therapeutic touch. C. effleurage. D. patterned breathing.

C. effleurage.

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? A. position B. attitude C. lie D. presentation

C. lie

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request? A. "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover." B. "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break." C. "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings." D. "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit."

D. "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit."

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states? A. "Effleurage is the pattern for cleaning the perineum before birth." B. "Effleurage is the effect of a full bladder on fetal descent." C. "Effleurage is massaging the perineum as the fetus enlarges the vaginal opening." D. "Effleurage is light abdominal massage used to displace pain."

D. "Effleurage is light abdominal massage used to displace pain."

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate? A. "Try doing Kegel exercises to get your pelvic muscles back in shape." B. "This is entirely normal, and many women go through it. It just takes time." C. "It takes a while to get your body back to its normal function after having a baby." D. "You might try using a water-soluble lubricant to ease the discomfort."

D. "You might try using a water-soluble lubricant to ease the discomfort."

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? A. 0 B. +4 C. +2 D. -2

D. -2

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? A. uterine atony B. uterine contraction C. uterine subinvolution D. uterine prolapse

A. uterine atony

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client? A. dilation of cervix diameter to 10 cm B. start of regular contractions C. rupturing of fetal membranes D. diffuse abdominal cramping

A. dilation of cervix diameter to 10 cm

During which time is the nurse correct to document the end of the third stage of labor? A. When the mother is moved to the postpartum unit B. Following fetal birth C. When pushing begins D. At the time of placental delivery

D. At the time of placental delivery

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia? A. McRoberts maneuver B. McDonald maneuver C. McRonald maneuver D. McGeorge maneuver

A. McRoberts maneuver

The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize? A. Meconium in the fluid B. Irregular contractions C. Possible maternal infection D. Fetal heart rate

A. Meconium in the fluid

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? A. atony B. normal involution C. hemorrhage D. infection

A. atony

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder? A. Mastitis B. Breast yeast C. Plugged milk duct D. Engorgement

A. Mastitis

A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed? A. tocolytic therapy B. anti-anxiety therapy C. bronchodilators D. muscle relaxants

A. tocolytic therapy

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. A. women using street drugs B. women on antithyroid medications C. women who had difficulties with breastfeeding in the past D. women on antineoplastic medications E. women with more than one infant

A. women using street drugs B. women on antithyroid medications D. women on antineoplastic medications

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement? A. "I will have a strong one and then the next one will be weaker." B. "I feel pressure in my vagina when I have the contraction." C. "The contractions lessen after I drink a large glass of water." D. "I feel the tightening primarily in the front of my belly."

B. "I feel pressure in my vagina when I have the contraction."

A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? A. The support person's access to the client should be limited to prevent the client from becoming overwhelmed. B. Women should be able to move about freely throughout labor. C. Routine intravenous fluid should be implemented. D. A woman should be allowed to assume a supine position.

B. Women should be able to move about freely throughout labor.

A client with a pendulous abdomen and uterine fibroid tumors has just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman? A. occipitoposterior position B. transverse lie C. anterior fetal position D. cephalic presentation

B. transverse lie

The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care? A. "I am able to pump my breast milk for my baby and throw away the milk." B. "When breastfeeding, it is recommended to begin nursing on the infected breast first." C. "I can continue breastfeeding my infant, but it may be somewhat uncomfortable." D. "I will stop breastfeeding until I finish my antibiotics."

C. "I can continue breastfeeding my infant, but it may be somewhat uncomfortable."

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant? A. "Many mothers who have lost an infant want pictures of the baby. Can I make some for you?" B. "Have you named your baby yet? I would like to know your baby's name." C. "I know you are hurting, but you can have another baby in the future." D. "I will make handprints and footprints of the baby for you to keep."

C. "I know you are hurting, but you can have another baby in the future."

The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment? A. Shorter dilation (dilatation) stage of labor B. Need to have the baby manually rotated C. Experience of additional back pain D. Necessity for vacuum extraction for birth

C. Experience of additional back pain

While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents? A.FHR fluctuates over 25 beats per minute. B. FHR fluctuates less than 5 beats per minute. C. FHR fluctuates from 6 to 25 beats per minute. D. FHR fluctuation range is undetectable.

C. FHR fluctuates from 6 to 25 beats per minute.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? A. Dry the nipples following feedings. B. Apply cold compresses to the breasts. C. Feed the baby at least every two or three hours. D. Provide the infant oral nystatin.

C. Feed the baby at least every two or three hours.

How does a woman who feels in control of the situation during labor influence her pain? A. There is no association between the two factors. B. Decreased feeling of control helps during the third stage. C. Feelings of control are inversely related to the client's report of pain. D. Feeling in control shortens the overall length of labor.

C. Feelings of control are inversely related to the client's report of pain.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? A. Avoid frequent breastfeeding. B. Apply cold compresses to the breast. C. Perform handwashing before breastfeeding. D. Avoid massaging the breast area.

C. Perform handwashing before breastfeeding.

Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation? A. General B. Local C. Regional D. Short acting

C. Regional

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign? A. "This indicates that you start labor within the next 24 hours." B. "This means +1 and the baby is entering the true pelvis." C. "This is just a way of determining your progress in labor." D. "The presenting part is at the true pelvis and is engaged."

D. "The presenting part is at the true pelvis and is engaged."

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? A. 750 mL B. 1000 mL C. 300 mL D. 500 mL

D. 500 mL

A nurse is making a follow up visit to a new parent and 3-month-old infant. The nurse is talking with the client about her role as a mother and caring for her infant. Which statement by the client would lead the nurse to immediately call the health care provider? A. "I am so angry with myself, I just want to give up my life right now." B. "I get tearful every so often and then suddenly I am all smiles." C. "I feel really restless and sad, nothing seems to make me happy." D. "It has been hard getting enough sleep with the infant waking up during the night."

A. "I am so angry with myself, I just want to give up my life right now."

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply. A. "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." B. "I am sad because I am not spending as much time with my toddler now that my newborn is here." C. "The newborn is not really mine emotionally, since I was never pregnant and do not have children." D. "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." E. "Sometimes I get tired of being with only the newborn, so I call my mom and sister to come visit."

A. "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." C. "The newborn is not really mine emotionally, since I was never pregnant and do not have children." D. "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts."

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior? A. bonding B. attachment C. being spoiled D. none of the above

A. bonding

A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to? A. place a hand gently on the fetal head to guide birth. B. ask her to push with the next contraction so birth is rapid. C. assess blood pressure and pulse to detect placental bleeding. D. attach a fetal monitor to determine fetal status.

A. place a hand gently on the fetal head to guide birth.

After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition? A. reports of severe back pain B. lack of cervical dilation past 2 cm C. fetal buttocks as the presenting part D. contractions most forceful in the middle of uterus rather than the fundus

A. reports of severe back pain

A nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum depression? Select all that apply. A. restlessness B. sleeping well C. feelings of worthlessness D. hunger E. feeling overwhelmed

A. restlessness B. sleeping well C. feelings of worthlessness D. hunger E. feeling overwhelmed

A nursing instructor teaching about risk factors associated with preterm labor should discuss which demographic and lifestyle issues? Select all that apply. A. smoking B. alcohol use C. hypertension D. low socioeconomic status E. infection F. high level of stress

A. smoking B. alcohol use D. low socioeconomic status F. high level of stress

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? A. taking-in B. letting-go C. acquaintance/attachment D. taking-hold

A. taking-in

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? A. +1 B. 0 C. +4 D. -5

C. +4

During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last? A. 2 station B. 0 station C. -4 station D. +4 station E. -2 station

C. -4 station E. -2 station B. 0 station A. 2 station D. +4 station

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned? A. Fetal size B. Fetal position C. Fetal attitude D. Fetal station

B. Fetal position

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? A. performing bimanual compressions B. notifying the primary care provider C. massaging the fundus firmly D. administering ergonovine

C. massaging the fundus firmly

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control? A. hydroxyzine hydrochloride B. secobarbital C. meperidine D. thiopental

C. meperidine

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? A. one fingerbreadth above the umbilicus B. at the level of the umbilicus C. one fingerbreadth below the umbilicus D. below the symphysis pubis

C. one fingerbreadth below the umbilicus

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately? A. pulse rate 75 beats per minute B. uterine fundus 1 cm below umbilicus C. oral temperature 100.8° F (38.2° C) D. respiratory rate 16 breaths/minute

C. oral temperature 100.8° F (38.2° C)

When palpating for fundal height on a postpartum woman, which technique is preferable? A. palpating the fundus with only fingertip pressure B. resting both hands on the fundus C. placing one hand at the base of the uterus, one on the fundus D. placing one hand on the fundus, one on the perineum

C. placing one hand at the base of the uterus, one on the fundus

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for? A. damage to the maternal tissues. B. increased risk for uterine rupture. C. potential lacerations and bleeding. D. increased risk for cord entanglement.

C. potential lacerations and bleeding.

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give? A. "It blocks the transmission of nerve messages of pain at the receptors." B. "It disrupts the nerve signal of pain via mechanical irritation of the nerves." C. "It causes the release of endorphins." D. "It distracts your brain from the sensations of pain."

D. "It distracts your brain from the sensations of pain."

A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement? A. "Our baby will come out with the buttocks first." B. "Our baby will come out facing the hip." C. "Our baby will come out with the back of the head first." D. "Our baby will come out face first."

D. "Our baby will come out face first."

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress? A. "There has been no further dilatation; effacement is progressing." B. Don't mention anything to the client yet; wait for further dilatation to occur. C. "You haven't dilated any further, but hang in there; it will happen eventually." D. "You are still 2 cm dilated, but the cervix is thinning out nicely."

D. "You are still 2 cm dilated, but the cervix is thinning out nicely."

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth? A. Avoid early ambulation to prevent respiratory problems. B. Delay breastfeeding the newborn for a day. C. Ensure that the client does not cough or breathe deeply. D. Assess uterine tone to determine fundal firmness.

D. Assess uterine tone to determine fundal firmness.

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching? A. Longitudinal B. Obtuse C. Oblique D. Transverse

A. Longitudinal

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? A. 500 additional calories per day B. 750 additional calories per day C. 250 additional calories per day D. 1,000 additional calories per day

A. 500 additional calories per day

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanel (fontanelle). The client is anxious to know when the posterior fontanel will close. Which time span is the normal duration for the closure of the posterior fontanel? A. 8 to 12 weeks B. 4 to 6 weeks C. 14 to 18 weeks D. 12 to 14 weeks

A. 8 to 12 weeks

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe? A. Administer oxytocin diluted as a "piggyback" infusion. B. Administer oxytocin diluted in the main intravenous fluid. C. Administer oxytocin in two divided intramuscular sites. D. Administer oxytocin in a 20 cc bolus of saline.

A. Administer oxytocin diluted as a "piggyback" infusion.

A G1 P1001 mother is just home after giving birth to her first child 5 days ago. Her birth was complicated by an emergency cesarean birth resulting from incomplete cervical dilation (dilatation) and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this client care issue is? A. At risk for postpartum depression due to inadequate rest. B. At risk for inadequate healing due to decreased nutrition. C. At risk for safety due to low hemoglobin. D. At risk for interruption of tissue integrity.

A. At risk for postpartum depression due to inadequate rest.

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? A. Difficulty breathing B. Decreased level of consciousness C. Intense pain D. Staggering gait

A. Difficulty breathing

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? A. Educate the client on how to perform Kegel exercises. B. Perform an in and out catheter on the client. C. Ask the client when she last urinated. D. Determine if the client is emptying her bladder.

A. Educate the client on how to perform Kegel exercises.

The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication? A. Excessive bleeding B. Urinary infection C. A ruptured bladder D. Bladder distention

A. Excessive bleeding

An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply. A. Has the mother ever been sensitized to Rh-positive blood? B. What was the birth weight of the infant? C. Has the mother had any previous pregnancies? D. Has the mother experienced any miscarriages or abortions? E. Has she delivered by cesarean section or vaginally?

A. Has the mother ever been sensitized to Rh-positive blood? C. Has the mother had any previous pregnancies? D. Has the mother experienced any miscarriages or abortions?

The nurse has provided care to a client throughout labor and delivery and is comparing assessment findings with expected norms. When tracking the client's cardiac assessments, the nurse should predict that cardiac output will likely be the highest at which time? A. Immediately after birth B. During transition C. During active labor D. Second stage of labor

A. Immediately after birth

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate? A. Instruct the client to empty her bladder before the examination. B. Perform the examination as quickly as possible. C. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. D. Wear sterile gloves when assessing the pad and perineum.

A. Instruct the client to empty her bladder before the examination.

A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? A. Look for late decelerations on monitor, which is associated with fetal anoxia. B. Monitor fetal movements to ensure they are neurologically intact. C. Monitor heart rate for tachycardia. D. Monitor fetal blood pressure for signs of shock (low BP, high FHR).

A. Look for late decelerations on monitor, which is associated with fetal anoxia.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain? A. Occiput posterior position B. Fetal macrosomia C. Nongynecoid pelvis D. Breech presentation

A. Occiput posterior position

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. As long as there is a prescription, what intervention would the nurse perform next? A. Perform urinary catheterization. B. Insert a 20 gauge IV. C. Administer oxytocin IV. D. Notify the health care provider.

A. Perform urinary catheterization.

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor? A. Radiates from the back to the front B. Slows when the woman changes position C. Lasts about 20 to 25 seconds D. Occurs in an irregular pattern

A. Radiates from the back to the front

The nurse is providing a report on a gravida 3 para 2 client. The nurse states that the client is fully effaced, 7 cm dilated, +1 station, and contractions every 8 minutes. Which nursing action is most important at this time? A. Record tocodynamometer readings. B. Ambulate the client in the hall. C. Obtain vital signs. D. Discuss contraction intensity.

A. Record tocodynamometer readings.

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate? A. She should continue to breastfeed; mastitis will not infect the neonate. B. She should stop breastfeeding until completing the antibiotic. C. She should not use analgesics because they are not compatible with breastfeeding. D. She should supplement feeding with formula until the infection resolves.

A. She should continue to breastfeed; mastitis will not infect the neonate.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? A. Staphylococcus aureus B. Streptococcus pyogenes (group A strep) C. Escherichia coli D. group B streptococcus (GBS)

A. Staphylococcus aureus

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement? A. Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. B. Dismiss the mother's concerns by telling her that you are sure she doesn't really mean it. C. Recommend rooming-in to foster attachment and confidence by the mother. D. Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge.

A. Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.

Which situation should concern the nurse treating a postpartum client within a few days of birth? A. The client feels empty since she gave birth to the neonate. B. The client would like to watch the nurse give the baby her first bath. C. The client is nervous about taking the baby home. D. The client would like the nurse to take her baby to the nursery so she can sleep.

A. The client feels empty since she gave birth to the neonate.

A woman in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the shape of the abdomen has changed. The nurse calls a code, and a cesarean birth is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement? A. The parents are beginning to demonstrate positive grieving behaviors. B. The parents just cannot believe their perfect infant died. C. The parents continue to mourn the loss of their infant. D. The parents are exhibiting dysfunctional coping mechanisms related to the death of their newborn.

A. The parents are beginning to demonstrate positive grieving behaviors.

During a postbirth home visit, the nurse asks the client to complete the Edinburgh Depression Scale. What information will the nurse learn from this scale? Select all that apply. A. To identify the need for additional support in the home B. To identify the client's attachment to the newborn C. To identify clients at risk for suicide D. To identify client at risk for perinatal depressions E. To identify the client's need for antidepressant medications

A. To identify the need for additional support in the home C. To identify clients at risk for suicide E. To identify the client's need for antidepressant medications

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort? A. Use a fist to apply counter pressure to the lower back. B. Have the primary care provider administer a pudendal block. C. Apply a warm washcloth to the lower back. D. Place the client supine with the head of bed elevated 30 degrees.

A. Use a fist to apply counter pressure to the lower back.

The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage? A. Uterine atony B. Hematoma C. Perineal lacerations D. Disseminated intravascular coagulation

A. Uterine atony

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? A. Uterine rupture B. Placenta previa C. Hypertonic uterus D. Umbilical cord compression

A. Uterine rupture

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client? A. an ice pack applied to the perineum B. a sitz bath C. narcotic pain medication D. a heating pad applied to the perineum

A. an ice pack applied to the perineum

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which action would the nurse include in the discussion as possible strategies for the new mothers to do? Select all that apply. A. avoiding smoking B. performing Kegel exercises C. starting jogging D. increasing fluid intake E. losing weight if obese

A. avoiding smoking B. performing Kegel exercises E. losing weight if obese

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound? A. continuing to monitor maternal and fetal status B. applying suprapubic pressure against the fetal back C. noting the space at the maternal umbilicus D. auscultating the fetal heart rate at the level of the umbilicus

A. continuing to monitor maternal and fetal status

The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point? A. counterpressure against the sacrum B. effleurage of the abdomen during the contraction C. conscious relaxation/guided imagery in low Fowler position D. pant-blow (breaths and puffs breathing techniques)

A. counterpressure against the sacrum

When teaching a group of nursing students about the different types of pelvis, the nurse describes which features of a gynecoid pelvis Select all that apply. A. dull ischial spines B. round-shaped inlet C. convergent side walls D. wide pubic arch E. straight sacrum

A. dull ischial spines B. round-shaped inlet D. wide pubic arch

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? A. every 15 minutes B. every 5 minutes C. every 10 minutes D. every 20 minutes

A. every 15 minutes

As a woman enters the second stage of labor, which would the nurse expect to assess? A. feelings of being frightened by the change in contractions B. reports of feeling hungry and unsatisfied C. falling asleep from exhaustion D. expressions of satisfaction with her labor progress

A. feelings of being frightened by the change in contractions

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. A. hydramnios B. uterine infection C. prolonged labor D. empty bladder E. breastfeeding F. early ambulation

A. hydramnios B. uterine infection C. prolonged labor

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? A. hypovolemia B. hyperglycemia C. hypertension D. hypothyroidism

A. hypovolemia

The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor? A. increased vaginal acidity leading to growth of bacteria B. prolonged labor with multiple vaginal examinations to evaluate progress C. retained placental fragments D. loss of protection with premature rupture of membranes

A. increased vaginal acidity leading to growth of bacteria

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately? A. moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 B. moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5 C. moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 D. lochia progresses from rubra to serosa to alba within 10 days

A. moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

To assess the frequency of a woman's labor contractions, the nurse would time? A. the beginning of one contraction to the beginning of the next. B. how many contractions occur in 5 minutes. C. the end of one contraction to the beginning of the next. D. the interval between the acme of two consecutive contractions.

A. the beginning of one contraction to the beginning of the next.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? A. touching B. talking C. looking D. feeding

A. touching

A pregnant client at 24 weeks' gestation comes to the clinic for an evaluation. The client called the clinic earlier in the day stating that she had not felt the fetus moving since yesterday evening. Further assessment reveals absent fetal heart tones. Intrauterine fetal demise is suspected. The nurse would expect to prepare the client for which testing to confirm the suspicion? A. ultrasound B. triple marker screening C. human chorionic gonadotropin (hCG) level D. amniocentesis

A. ultrasound

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis? A. Assess for redness and warmth. B. Dorsiflex her right foot and ask if she has pain in her calf. C. Ask about increased pain with weight bearing. D. Ask if she has pain or tenderness in the lower extremities.

B. Dorsiflex her right foot and ask if she has pain in her calf.

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern? A. "You may have developed mastitis. I'll ask the primary care provider to examine you." B. "It takes about 3 days after birth for milk to begin forming." C. "I'm sorry to hear that. There are some excellent formulas on the market now, so you will still be able to provide for your infant's nutritional needs." D. "You are experiencing lactational amenorrhea. It may be several weeks before your milk comes in."

B. "It takes about 3 days after birth for milk to begin forming."

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? A. "You would probably be more successful if you wrapped him in on a warm blanket." B. "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." C. "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?" D. "Let me show you how to calm him down. I've been doing this for many years."

B. "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

A nurse is assessing the perineum of a postpartum woman using the REEDA scale. The woman is one day postpartum. The nurse notes that the woman has serous discharge. Which score would the nurse assign this finding? A. 2 B. 1 C. 3 D. 0

B. 1

A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate? A. Assist with insertion of a central venous access device for administration. B. Administer the medication piggybacked into a primary IV line using a pump. C. Give the medication orally every hour for the first 4 hours. D. Give the medication as an intramuscular injection using the Z-track technique.

B. Administer the medication piggybacked into a primary IV line using a pump.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering? A. Assess for dry mouth. B. Assess fetal heart rate. C. Assess for constipation. D. Assess maternal blood pressure.

B. Assess fetal heart rate.

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? A. Ask her to raise her foot and draw a circle. B. Assess for pedal edema. C. Blanch a toe, and count the seconds it takes to color again. D. Bend her knee, and palpate her calf for pain.

B. Assess for pedal edema.

A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation to occur? A. Bloody show B. Cervical ripening and softening C. Braxton Hicks contractions D. Lightening

B. Cervical ripening and softening

A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client? A. Breastfeed or otherwise empty your breasts at least every 3 hours. B. Complete the full course of antibiotic prescribed, even if you begins to feel better. C. Use NSAIDs, warm showers, and warm compresses to relieve discomfort. D. Increase your fluid intake to ensure that you will continue to produce adequate milk.

B. Complete the full course of antibiotic prescribed, even if you begins to feel better.

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? A. Consistency, location, and place B. Consistency, shape, and location C. Location, shape, and content D. Content, lochia, place

B. Consistency, shape, and location

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? A. Apply ice packs directly to the perineal area. B. Ensure ice pack is changed frequently. C. Apply ice packs for 40 minutes continuously. D. Use ice packs for a week after birth.

B. Ensure ice pack is changed frequently.

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize? A. Assess her blood pressure. B. Palpate her fundus. C. Have her turn to her left side. D. Assess her perineum.

B. Palpate her fundus.

A postpartum client who was discharged home returns to the primary health care facility after 2 weeks with reports of fever and pain in the breast. The client is diagnosed with mastitis. What education should the nurse give to the client for managing and preventing mastitis? A. Avoid hot or cold compresses on the breast. B. Perform hand-washing before and after breastfeeding. C. Discontinue breastfeeding to allow time for healing. D. Discourage manual compression of breast for expressing milk.

B. Perform hand-washing before and after breastfeeding.

The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? A. Genetic abnormality B. Placental abruption C. Premature rupture of membranes D. Preeclampsia

B. Placental abruption

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? A. A breast abscess is a common complication of mastitis. B. Symptoms include fever, chills, malaise, and localized breast tenderness. C. Mastitis usually develops in both breasts of a breastfeeding client. D. The most common pathogen is group A streptococcus (GAS).

B. Symptoms include fever, chills, malaise, and localized breast tenderness.

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding? A. The uterine placement is normal. B. The bladder is distended. C. There is an infection inside the uterus. D. The uterus is filling up with blood.

B. The bladder is distended.

When assessing the postpartum client 2 hours after giving birth, which finding indicates the need for further action? A. The fundus is firm and located one fingerbreadth below the level of the umbilicus. B. The fundus is firm and deviated sharply to the right side of the abdomen. C. The fundus is firm and located 1 fingerbreadth above the level of the umbilicus. D. The fundus is firm and located at the level of the umbilicus.

B. The fundus is firm and deviated sharply to the right side of the abdomen.

The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartum blues? A. an 18-year-old mother who is currently holding her baby and looking face-to-face at the baby without saying a word B. a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding C. a 29-year-old mother who has lots of family visiting, offering to help her with meals and cleaning for the next few months D. a 38-year-old G1P1 who is constantly holding the baby and touching the baby's hands and fingers

B. a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? A. a scant amount of lochia alba B. a moderate amount of lochia rubra C. a scant amount of lochia serosa D. a moderate amount of lochia alba

B. a moderate amount of lochia rubra

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to? A. tell the woman to take short, catchy breaths. B. administer oxygen by mask. C. increase her intravenous fluid infusion rate. D. put firm pressure on the fundus of her uterus.

B. administer oxygen by mask.

The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding? A. poor in quality. B. erratic. C. well coordinated. D. brief.

B. erratic.

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? A. fetal position B. external electronic fetal monitoring C. fetal oxygen saturation D. fetal blood pH

B. external electronic fetal monitoring

A postpartum woman has a history of von Willebrand disease (vWD). The client is being prepared for discharge, and a referral for health care follow up is made to assess for potential postpartum hemorrhage. The nurse understands that this client is at greatest risk for hemorrhage during which time during the postpartum period? A. first month B. first week C. first 3 days D. first 6 weeks

B. first week

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? A. lying supine with legs in lithotomy stirrups B. head elevated, grasping knees, breathing out C. squatting while holding her breath D. lying on side, arms grasped on abdomen

B. head elevated, grasping knees, breathing out

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? A. cracking of the nipple B. inability of infant to empty breasts C. inadequate secretion of prolactin D. improper positioning of infant

B. inability of infant to empty breasts

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply. A. increase in gastric emptying and pH B. increase in respiratory rate C. increase in blood pressure D. slight decrease in body temperature E. increase in heart rate

B. increase in respiratory rate C. increase in blood pressure E. increase in heart rate

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? A. pulmonary emboli B. infection C. depression D. hemorrhage

B. infection

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time? A. less than 5 hours B. less than 3 hours C. less than 8 hours D. less than 4 hours

B. less than 3 hours

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post-cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments? A. lower extremities B. perineum C. respiratory status D. breasts

B. perineum

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? A. hormonal shifting of relaxin and estrogen B. thromboembolic disorder of the lower extremities C. normal response to the body converting back to prepregnancy state D. infection

B. thromboembolic disorder of the lower extremities

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? A. a client who had an 8-hour labor B. a client who conceived following fertility treatments C. a client who had a nonelective cesarean birth D. a primiparous client who had a vaginal birth

C. a client who had a nonelective cesarean birth

The nurse is reviewing the medical record of a woman for whom induction of labor is being considered. The nurse notes the following: Cervical dilation 4 cm Effacement 60% 0 Station Soft cervix Anterior cervical position. Based on this information, which Bishop score would the nurse assign? A. 6 B. 8 C. 10 D. 12

C. 10

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? A. Height, level of orientation, support systems B. Degree of responsiveness, respiratory rate, fundus location C. Blood pressure, pulse, reports of dizziness D. Attachment, lochia color, complete blood cell count

C. Blood pressure, pulse, reports of dizziness

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client? A. Call her caregiver if amount of lochia decreases. B. Call her caregiver if lochia moves from serosa to alba. C. Call her caregiver if lochia moves from serosa to rubra. D. Call her caregiver if lochia moves from rubra to serosa.

C. Call her caregiver if lochia moves from serosa to rubra.

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway? A. Perineum B. Uterus C. Cervix D. False pelvis

C. Cervix

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? A. Assess the temperature. B. Monitor the pain level. C. Check the lochia. D. Assess the fundal height.

C. Check the lochia.

The nurse would prepare a client for amnioinfusion when which action occurs? A. The fetus shows abnormal fetal heart rate patterns. B. Fetal presenting part fails to rotate fully and descend in the pelvis. C. Severe variable decelerations occur and are due to cord compression. D. Maternal pushing is compromised due to anesthesia.

C. Severe variable decelerations occur and are due to cord compression.

A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period? A. She has not asked for anything for pain all day. B. She is eager to talk about her birth experience. C. She did her perineal care independently. D. She sits and rocks her infant for long intervals.

C. She did her perineal care independently.

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? A. Her uterus is soft to your touch. B. The flow is over 500 mL. C. The color of the flow is red. D. The flow contains large clots.

C. The color of the flow is red.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? A. Administer oxygen at 3 to 4 L by nasal cannula. B. Ask her to pant with the next contraction. C. Turn her or ask her to turn to her side. D. Help the woman to sit up in a semi-Fowler's position.

C. Turn her or ask her to turn to her side.

A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give? A. Avoid using soap for any perineal care. B. Refrain from washing lochia from the suture line. C. Wash her perineum with her daily shower. D. Use an alcohol wipe to wash her episiotomy line.

C. Wash her perineum with her daily shower.

There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain? A. Women report higher levels of satisfaction when regional anesthetics are used to control pain. B. Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. C. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. D. Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain.

C. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct? A. You should be able to resume normal activities after 2 weeks. B. You need to hire a maid for the first month after delivery to help out around the house. C. You should not lift anything heavier than your infant in its carrier. D. Only clean half of the house per day to allow yourself more rest.

C. You should not lift anything heavier than your infant in its carrier.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? A. prostaglandin B. laminaria C. amniotomy D. breast stimulation

C. amniotomy

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of? A. maladjustment to parenting. B. lack of partner support. C. postpartum depression. D. postpartum blues.

C. postpartum depression.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to? A. prepare the client for which test first? B. noninvasive arterial studies of the right leg C. venous duplex ultrasound of the right leg D. transthoracic echocardiogram E. venogram of the right leg

C. venous duplex ultrasound of the right leg

Which client outcome during active and transitional labor is best? A. The client will state a pain level of 7 and under during contractions. B. The client will tolerate 8 oz (240 ml) of clear liquids during labor process. C. The client will walk in the hall for 15 minutes every 2 hours. D. The client will practice breathing techniques during contractions.

D. The client will practice breathing techniques during contractions.

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? A. "I need to avoid using any aspirin-containing products." B. "If I get a cut, I need to apply direct pressure for about 5 minutes or more." C. "If my lochia increases, I need to call my health care provider." D. "I should brush my teeth vigorously to stimulate the gums."

D. "I should brush my teeth vigorously to stimulate the gums."

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response? A. Tell the client that she must go home as per hospital policy. B. Inform the primary care provider that the client does not want to go home. C. Ask the client if she has any support in the home. D. Ask the client to explain why she does not want to go home.

D. Ask the client to explain why she does not want to go home.

The nurse is teaching a class to a group of pregnant women in their second trimester. Which information about the effects of maternal position on labor will the nurse include? A. The lithotomy position allows gravity to move the fetus downward. B. Lying supine causes less abnormal fetal heart rate patterns. C. A kneeling position puts pressure on the vena cava. D. Being upright promotes a sense of control for the mother.

D. Being upright promotes a sense of control for the mother.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? A. Ask if the client received rH immunoglobulins during the pregnancy. B. Determine if this is the client's first baby. C. Administer Rh immunoglobulins intramuscularly. D. Determine the newborn's blood type and rhesus.

D. Determine the newborn's blood type and rhesus.

What term is used to describe the position of the fetal long axis in relation to the long axis of the mother? A. Fetal presentation B. Fetal position C. Fetal attitude D. Fetal lie

D. Fetal lie

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? A. Change the perineal pad every 3 to 4 hours to decrease the uterine infection. B. Apply ice to the perineum to decrease pain of a perineal infection. C. Drink plenty of fluids to decrease a bladder infection. D. Finish all antibiotics to decrease a genital tract infection.

D. Finish all antibiotics to decrease a genital tract infection.

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation? A. Normal vital signs B. Dehydration C. Shock D. Infection

D. Infection

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? A. Pointing out specific features in the newborn B. Having feelings of grief or guilt C. Talking about her labor experience to others around her D. Showing increased confidence when caring for the newborn

D. Showing increased confidence when caring for the newborn

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor? A. The client has contractions once every two minutes. B. The client experiences her first full contraction. C. The infant is born. D. The client's cervix is fully dilated.

D. The client's cervix is fully dilated.

The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive? A. The parents explore the newborn's extremities, counting fingers and toes. B. The father holds the newborn en face and talks to her. C. The mother states that she has her father's eyes. D. The mother is reluctant to touch the newborn for fear of hurting her.

D. The mother is reluctant to touch the newborn for fear of hurting her.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? A. The mother may have continued memory loss postpartum. B. The father's coaching role may be disrupted at times. C. The infant may show increased drowsiness. D. The mother may have difficulty working effectively with contractions.

D. The mother may have difficulty working effectively with contractions.

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which role do Braxton Hicks contractions play in aiding labor? A. These contractions increase the release of prostaglandins. B. These contractions make maternal breathing easier. C. These contractions increase oxytocin sensitivity. D. These contractions help in softening and ripening the cervix.

D. These contractions help in softening and ripening the cervix.

A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? A. Walk the length of the hallway to regain her strength. B. Avoid elevating her feet when she rests in a chair. C. Avoid getting out of bed for another 2 days. D. Walk with the nurse the length of her room.

D. Walk with the nurse the length of her room.

The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client? A. talking to the client and reassuring her that she will feel better soon B. scheduling electroconvulsive therapy C. telling the client that she has no need to be depressed D. administrating a selective serotonin reuptake inhibitor

D. administrating a selective serotonin reuptake inhibitor

An adolescent primipara was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with the baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as: A. engrossment. B. involution. C. engorgement. D. attachment.

D. attachment.

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth? A. assess for cleft palate B. extensive lacerations C. monitor for a cardiac anomaly D. brachial plexus assessment

D. brachial plexus assessment

The LVN/LPN will be assessing a postpartum client for danger signs of infection after a vaginal birth. What assessment finding would the nurse assess as a possible sign of infection for this client? A. presence of lochia rubra B. fundus is above the umbilicus C. fundus is firm D. fever more than 100.4° F (38° C)

D. fever more than 100.4° F (38° C)

The nurse is caring for a client in labor. The nurse realizes it is most common for labor dystocia to occur during which stage of labor? A. second stage of labor B. third stage of labor C. fourth stage of labor D. first stage of labor

D. first stage of labor

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? A. whenever the couple wishes B. usually within a couple weeks C. generally after 12 weeks D. generally within 3 to 6 weeks

D. generally within 3 to 6 weeks

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? A. infection B. nothing—it is normal C. DVT D. hematoma

D. hematoma

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will? A. press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist. B. instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale. C. lead the client through a series of visualizations to aid in relaxation. D. instruct the client or her partner to perform light fingertip repetitive abdominal massage.

D. instruct the client or her partner to perform light fingertip repetitive abdominal massage.

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and: A. pH. B. consistency. C. specific gravity. D. odor.

D. odor.

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? A. multiparity B. hemoglobin of 11.5 mg/dl (115 g/L) C. labor less than 3 hours D. placenta removed via manual extraction

D. placenta removed via manual extraction

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? A. postpartum depression B. postpartum blues C. postpartum panic disorder D. postpartum psychosis

D. postpartum psychosis

A nurse is explaining to a pregnant client about the changes occurring in the body in preparation for labor. Which hormone would the nurse include in the explanation as being responsible for causing the pelvic connective tissue to become more relaxed and elastic? A. prolactin B. oxytocin C. progesterone D. relaxin

D. relaxin

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the postpartum restorative period is this client in? A. taking-hold phase B. letting-go phase C. rooming-in phase D. taking-in phase

D. taking-in phase

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? A. moderate amount of lochia rubra B. hemoglobin level of 12 g/dl (120 g/L) C. thrombophlebitis D. uterine atony

D. uterine atony