Exam IV Study Set

The nurse provides discharge instructions to a postpartum patient. Which patient statement indicates that teaching has been effective?

"I should plan to return to my full-time job after 6 weeks."

A postpartum client reports urinary frequency and burning. What cause would the nurse suspect?

UTI

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?

"I can't wait for these stretch marks to disappear after I give birth."

An 20-year-old primipara is getting ready to go home. She had a second-degree episiotomy with repair. She confides in the nurse that she is afraid to go to her postpartum checkup because she is afraid to have the stitches removed. Which reply by the nurse is best?

"Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed."

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:

"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."

The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate?

"Walking is the best way to prevent complications such as blood clots.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad

A postpartum woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartum?

Assess for calf redness and edema

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?

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

Which assessment finding 1 hour after birth should be reported to the health care provider?

Lochia rubra is saturating a pad every 45 to 60 minutes.

Which postpartum client will the nurse assess first?

a 35-year-old who had estimated blood loss of 700 ml and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?

apply ice

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

at the level of the umbilicus

A postpartum client's care provider has prescribed a stool softener. When providing health education to the client, the nurse should teach the client to:

drink plenty of fluids while taking the medication

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client?

fever >100.4

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel?

fundus two fingerbreadths below umbilicus and firm

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

lochia rubra

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?

oxytocin

The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?

postpartum depression

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?

the color of the flow is red

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 100 to 200 ml with each hourly void. How would the nurse interpret this finding?

the urinary output is normal

Which body system is most vulnerable to infection during the postpartum period?

urinary

During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this?

Urinary elimination

A nurse is assessing uterine involution of a postpartum woman. When reviewing the woman's labor and birth record, which factor would the nurse identify as potentially delaying involution? Select all that apply.

birth of triplets, grand multi-parity, hyraminos

The nurse is caring for a client is who 24-hours post-delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time?

hemoglobin & hematocrit

During the assessment, the nurse observes a separation of the rectus muscle that is more than two fingerbreadths wide. Which instruction should the nurse offer the client?

avoid lifting heavy object

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?

1cm below the umbilicus

When assessing a client's uterine fundus during the fourth stage of labor, the nurse palpates a soft, uncontracted fundus. Which of the following would the nurse do next?

Gently massage the boggy fundus

The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?

Involution

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?

The fundus is located 2 fingerbreadths above the umbilicus

Which reason explains why women should be encouraged to perform Kegel exercises after birth?

They promote blood flow, enabling healing and muscle strengthening

When assessing a postpartum mother, the nurse asks the client how many peripads she has used over the last 4 hours. The mother responds that she has changed her pad 2 to 3 times per hour when they were saturated. What action should the nurse take?

notify the RN of the finding

The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize?

hemorrhage

The nurse is assessing a postpartum client's vital signs 24 hours after the birth of her infant and notes: respirations 18, pulse 110 bpm, temperature 100.1°F (37.8°C), and blood pressure 128/88. Which assessment finding should the nurse prioritize for further attention?

pulse

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.

uterine infection, prolonged labor, hydraminos

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?

uterus 1cm below umbilicus