OB-new

The nurse has just completed discharge teaching for a primiparous client. Which statement by the client indicates to the nurse understanding of discharge instructions following vaginal delivery of a term infant? "I will call my doctor if my uterus is soft when I massage it." "I will experience heavy bleeding for the first week." "I should change my peri pad twice a day." "I might notice a foul smell to my discharge."

"I will call my doctor if my uterus is soft when I massage it."

A nurse in the provider office is assessing a patient who is deaf and uses sign language for communication. The patient is married to a partner who is also deaf. The couple expresses interest in attempting pregnancy. How does the nurse best respond to the couple? "Are you sure that's a good idea, because you're both hard of hearing?" A nurse in the provider office is assessing a patient who is deaf and uses sign language for communication. The patient is married to a partner who is also deaf. The couple expresses interest in attempting pregnancy. How does the nurse best respond to the couple? "Are you sure that's a good idea, because you're both hard of hearing?" "Are there adaptations that would help you with an infant?" "But how would you know the baby was crying?" "The provider will talk to you about ways to adapt your lifestyle for a baby."

"Are there adaptations that would help you with an infant?"

What statement made by a primiparous client 4 hours post delivery requires further assessment by the nurse? "Is it normal for it to burn when I go pee?" "My uterus is cramping when I breastfeed." "I'd like to see a lactation consultant about breastfeeding." "Will you take the baby to the nursery so I can nap?"

"Is it normal for it to burn when I go pee?"

The postpartum nurse is educating a client who is preparing to go home from the hospital. Which statements made by the client indicate understanding of contraceptive use after childbirth? "Just because I am breastfeeding does not mean I cannot get pregnant." "I do not need to use condoms until I stop breastfeeding." "I will need to use contraception once I get my period." "Breastfeeding is an effective form of birth control." "I do not need to use contraceptives for the first 6 weeks."

"Just because I am breastfeeding does not mean I cannot get pregnant."

The nurse walks into a postpartum room noting a screaming infant in a crib near the bedside. Both parents are asleep. Which statement by the mother shows the need for further assessment for ineffective bonding? "Sorry, it won't stop crying, and we are so tired." "We are so tired, she kept us up all night." "We are so tired, we must have been sound asleep." "We are so tired. What if this happens at home?"

"Sorry, it won't stop crying, and we are so tired."

During discharge education, the nurse notes the postpartum patient starting to fall asleep. What is the appropriate nursing response to the patient? "You will need to stay awake to learn this important information." "You should rest while the baby is asleep, and I will come back later to review this information." "You will not be able to go home until tomorrow, because you are having trouble staying awake still." "You can nap and I will justr eview this information with your partner."

"You should rest while the baby is asleep, and I will come back later to review this information."

The nurse is caring for a G2P2002 client who is Rh-negative and both her infants were Rh-positive. The nurse knows this client should have received the Rho (D) immune globulin (RhoGAM) shot how many times total during her childbearing years? a. 1 b. 4 c. 2 d. Never

4

The postpartum nurse is preparing to ambulate a client who received an epidural. What is the priority nursing intervention for this client? A. Assess for decreased nerve sensation. B. Assess for vaginal bleeding. C. Assess for bladder distention. D. Assess for spinal headache.

A. Assess for decreased nerve sensation.

During a routine assessment, the nurse notes diastasis recti abdominis on a postpartum client. What is the priority nursing intervention for this client? A. Continue with the assessment, as this is a normal finding. B. Notify the physician or midwife STAT. C. Assist the woman in applying an abdominal binder. D. Instruct the woman to avoid using her abdominal muscles.

A. Continue with the assessment, as this is a normal finding.

A nurse is caring for a client 2 hours post-vaginal delivery of a term neonate. The client suddenly complains of heavy bleeding, nausea, and dizziness. Vital signs are blood pressure (BP) 85/49, heart rate (HR) 110, respiratory rate (RR) 18, O2 saturation 90%, temp 98.3°F. Based on these assessment findings, what is the priority nursing intervention? Remove the infant from the room. Achieve free-flowing venous access. Increase frequency of vital signs. Prepare for emergency dilation and curettage.

Achieve free-flowing venous access.

The student nurse is assisting with discharging an adolescent patient on the postpartum unit. Discharge education on newborn care will need to be provided. What is the student nurse's priority action in preparing the education session? Prepare a video for the adolescent to watch on newborn care. Ask the maternal grandmother what has already been taught at home on newborn care. Ask the adolescent what she knows about newborn care. Insist that the father of the infant be present for the discharge education.

Ask the adolescent what she knows about newborn care.

The nurse on a postpartum unit is recalling how to be culturally competent when she is assigned a primiparous family from Japan. What actions by the nurse would show cultural competence? Select all that apply. Bringing the mother a pitcher of ice watere very few hours Asking the father of the infant if there is any things he can show or discuss with him about his new infant Asking the mother if she has any food preferences the nurse should let nutrition services know about Taking the infant to the nurse's station for several hours so the parents can rest and the mother can shower Showing people in the room who are visiting where the infant supplies and snack room are located

Asking the father of the infant if there is any things he can show or discuss with him about his new infant Asking the mother if she has any food preferences the nurse should let nutrition services know about Showing people in the room who are visiting where the infant supplies and snack room are located

The postpartum nurse is caring for a client who gave birth vaginally 2 hours ago. The nurse notices continued heavy bleeding with firm fundal tone. What nursing action is a priority for this client? Assess for the presence of a vaginal laceration. Perform vigorous fundal massage. Manually extract retained placental fragments. Document the findings as within normal limits.

Assess for the presence of a vaginal laceration.

The nurse notes a new mother is not making eye contact with her infant. What action should the nurse take? Check for other positive indications of bonding. Refer the patient to social work for work or behavior. The nurse should delay discharge and make the patient stay another day. Nothing, she is just a new and inexperienced mother.

Check for other positive indications of bonding.

A nurse is caring for a postpartum client who had an uncomplicated delivery 6 hours ago. Vital signs are blood pressure (BP) 125/88, heart rate (HR) 90, O2 saturation 98%, temperature 100.0°F. What is the priority nursing intervention? Document as with in normallimits. Administer acetaminophen 650 mg PO PRN. Notify the physician or midwife. Remove extra blankets and recheck in 1 hour.

Document as with in normallimits.

During routine assessment, a nurse caring for a postpartum client notes the uterus is shifted to the side. What is the priority nursing intervention? A. Notify the physician or midwife. B. Document the findings in the electronic medical record (EMR). C. Perform gentle fundal massage. D. Assist the woman to the bathroom.

D. Assist the woman to the bathroom.

Immediately after birth, the nurse notes the client's fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action? Document the findings as with in normal limits. Perform fundal massage. Instruct the woman to empty her bladder. Reassess every 5 minutes.

Document the findings as with in normal limits.

What can the nurse suggest to the multiparous mother who has concerns about her child feeling abandoned when the new baby arrives? Select all that apply. Encourage them to get in bed at the hospital with Mom. Bring the older sibling to the hospital as soon as possible to meet the new sibling. Take the sibling to the sitter so she can sleep. Prepare meals. Invest in an infant carrier.

Encourage them to get in bed at the hospital with Mom. Bring the older sibling to the hospital as soon as possible to meet the new sibling. Invest in an infant carrier.

During an office visit 2 weeks' postpartum, a G3P3003 patient mentions an increase in her stress level following delivery of this child. The nurse explains that the increase may be attributed to which considerations? Select all that apply. Increase in child care tasks Financial concerns Lack of paternal participation Increase in fatigue level Decrease in partner intimacy

Increase in child care tasks Financial concerns Increase in fatigue level

When planning care for the following patients, the postpartum nurse anticipates having little to no concerns about bonding with which couplet? Infant born at 28 weeks' gestation Labor lasting 8 hours Gestational diabetes during the pregnancy Patient recently separated from spouse

Labor lasting 8 hours

When performing a fundal assessment on a client, 2 hours following an uncomplicated vaginal delivery, the postpartum nurse notes a boggy uterus. What is the priority nursing action for this client? Massage the fundus with the palm of the hand. Place an indwelling catheter. Notify the physician or midwife. Give oxytocin as per the physician's orders.

Massage the fundus with the palm of the hand.

The nurse is caring for a patient after delivery. The patient and the father of the infant recently broke up. The nurse is discussing co-parenting with the patient. What would not be included in the conversation? Parenting time is equally split between parents. Parents share responsibility in parenting the child. Parents support each other in childcare decisions. Parents can be a part and still co-parent successfully.

Parenting time is equally split between parents.

A nurse is caring for a client in the immediate postpartum period. Upon assessment, the nurse notes heavy bleeding and a boggy uterus that does not respond to fundal massage. What are the priority nursing actions? Place in the correct order Perform fundal massage -> Titrate the standing order of oxytocin as appropriate -> notify the physician or midwife of excessive blood loss -> increase frequency of vital signs

Perform fundal massage -> Titrate the standing order of oxytocin as appropriate -> notify the physician or midwife of excessive blood loss -> increase frequency of vital signs

The nurse is preparing to educate an adolescent couple on infant care 2 days after delivery. What is the most appropriate consideration for the nurse during the education session? Ask the grandparents to leave the room. Only tell the father about the expectations of visiting because he doesn't live with the mother. Present the information in an engaging way that is age appropriate. Open the door and curtain to the hallway.

Present the information in an engaging way that is age appropriate.

The nurse is doing her morning assessment on a G1P1 client who delivered 6 hours ago. The client has ambulated to the restroom and voided, has latched the infant twice with no discomfort, and has eaten 90% of her breakfast. Her fundus is below her umbilicus and firm, lochia is small to moderate, rubra is present, and she has a second-degree laceration. Which of the following is a non pharmacological intervention appropriate for this client? Administer 600mg of ibuprofen. Provide her with a sitz bath and educate her on its use. Provide her with a breast pump. Perform fundal massage.

Provide her with a sitz bath and educate her on its use.

A postpartum nurse is caring for a client 48 hours post-vaginal delivery. The client's laboratory values are blood type A positive, group B strep positive, rubella non-immune, hepatitis B negative. Based on these assessment findings, what order should be questioned by the nurse? Measles, mumps, and rubella (MMR) vaccine subcutaneously Rho (D) immune globulin (RhoGAM) 300 mcg IM Ibuprofen 600 mg PRN every 6 hours Docusate sodium 100 mg BID

Rho (D) immune globulin (RhoGAM) 300 mcg IM

A nurse observes a 14-year-old and her new baby. The nurse notes the grandmother doing most of the holding and care of the infant. What is the appropriate nursing intervention? Show the patient more baby care videos and ask if she is depressed. Tell the mother,"It's time to grow up." Point out how well the grandmother is doing with the infant. Tell the patient how well she does when she performs care activities for the infant.

Tell the patient how well she does when she performs care activities for the infant.

The nurse assesses a mother's bonding with her new baby. Which action made by the mother does the nurse identify as the initial maternal phase? The mother relives and speaks of the birthing experience. The mother responds to and picks up the infant when she cries. The mother shows signs of baby blues. The mother asks questions about infant care.

The mother relives and speaks of the birthing experience.

A postpartum nurse is caring for a client who gave birth 1 hour ago following a 24-hour long induction. The client had an epidural for pain control during labor. What assessment finding should immediately be reported to the health-care provider? Uterine atony Bilateral lower extremity numbness Uncontrollable shaking Moderate vaginal bleeding

Uterine atony

A client on the postpartum unit reports passing an egg-sized clot. What are the priority nursing interventions for this client? Select all that apply. Weigh the clot. Examine the clot for the presence of tissue. Assist the client to the bathroom. Administer oxytocin 10 units IM. Call for rapid response.

Weigh the clot. Examine the clot for the presence of tissue.

The postpartum nurse is preparing to administer Rho (D) immune globulin (RhoGAM) to a post-cesarean section client on the mother-baby unit. What statements made by the client indicate an understanding of RhoGAM? Select all that apply. a. "I need this because my blood type is negative and my baby is positive." b. "I will avoid pregnancy for 4weeks." c. "This medication will help protect my future babies." d. "I only need to get this once in my life time." e. "I need to receive RhoGAM within 48 hours of giving birth."

a. "I need this because my blood type is negative and my baby is positive." c. "This medication will help protect my future babies."

34. A postpartum client reports urinary frequency, urgency, and pain with urination. What is the priority nursing intervention for this client? a. Assess the client's temperature. b. Instruct the client to use the peri-bottle when she voids. c. Assist the client with a sitz bath. d. Send a urine specimen for culture and sensitivity.

a. Assess the client's temperature.

A nurse is educating a client on the mother-baby unit about breastfeeding. Which statements made by the client indicate the need for further teaching? Select all that apply. a. "During the first 24 hours postpartum, my breasts should be soft and non tender." b. "Colostrum gives my baby protection from viruses and bacteria." c. "Colostrum is thick and whitish in color." d. "Colostrum has more carbohydrates than breast milk." e. "I might feel throbbing pain in my breasts for the first 1 to 2 days."

c. "Colostrum is thick and whitish in color." d. "Colostrum has more carbohydrates than breast milk."

A patient on the postpartum unit mentions a concern to the nurse about the baby bonding with the father. The nurse discusses the relationships formed between parents and infants. Which component does the nurse discuss as bidirectional? a. Love b. Admiration c. Bonding d. Attachment

d. Attachment

A nurse is educating a client about deep vein thrombosis (DVT) during discharge teaching. What information should be included in the discharge plan? Select all that apply. "Hit your call light when you are ready to get out of bed for the first time." "Avoid crossing your legs while sitting." "If either leg develops any redness or swelling,or becomes painful, be sure to contact your provider right away." "Make sure not to walk around too much." "Massage your calves daily to prevent a blood clot."

"Avoid crossing your legs while sitting." "If either leg develops any redness or swelling,or becomes painful, be sure to contact your provider right away."

What information is important for the postpartum nurse to include when educating a client receiving the measles, mumps, and rubella (MMR) vaccine after childbirth? Select all that apply. "Avoid pregnancy for 4 weeks after receiving the vaccine." "Report a temperature over 99.0°F (37.2°C) to your physician or midwife." "You are receiving this vaccine because you are not immune to the rubella virus." "You may experience pain, redness, and swelling around the injection site." "You will only need this vaccine once in your lifetime."

"Avoid pregnancy for 4 weeks after receiving the vaccine." "You are receiving this vaccine because you are not immune to the rubella virus." "You may experience pain, redness, and swelling around the injection site."

While in the room assessing an infant on the day of discharge, the nurse notes that the infant is awake and alert. The parents question why the infant is making cooing sounds. What is the appropriate nursing response? "Cooing demonstrates a normal neonatal reflex." "Those sounds don't mean anything." "Only worry if the baby is crying." "Cooing is one way the infant tries to communicate early on."

"Cooing is one way the infant tries to communicate early on."

A postpartum client expresses concern that she will get a blood clot in her leg because her mother had one after her delivery. What is the most therapeutic response by the nurse? "Blood clots do not runin families, so you have nothing to worry about." "I understand your concern. Let's take a look at the back of your legs together." "Women are only at risk for developing blood clots during pregnancy." "I will assist you to ambulate around the hallway so that doesn't happen."

"I understand your concern. Let's take a look at the back of your legs together."

The nurse is assessing the interaction between a newborn and his father. Which statement by the father shows adaptive paternal-infant bonding? Select all that apply. "I will stay awake with the baby while his mother sleeps." "We're tired, can you take him to the nursery?" "I don't change diapers." "Will you help me wrap him up?" "He looks like his mom."

"I will stay awake with the baby while his mother sleeps." "Will you help me wrap him up?"

20. Which response by a postpartum client indicates to the nurse the client understands uterine involution? Select all that apply. "My uterus will stay this big untilI get my period again." "It will take between 6 and 8 weeks for my uterus to return to normal size." "Contractions will cause my uterus to shrink." "In about 7weeks, I won't be able to feel my uterus." "If there are any complications like infection, my uterus won't shrink as much."

"It will take between 6 and 8 weeks for my uterus to return to normal size." "Contractions will cause my uterus to shrink." "If there are any complications like infection, my uterus won't shrink as much."

When discussing feeding options with a lesbian couple for their newborn, the nurse notes that both women would like to breastfeed. What is the appropriate nursing response? "Because only one of you conceived, only one of you can breastfeed." "It's not uncommon for both mothers to breastfeed. I will get you in touch with a lactation consultant to help." "Even though you both want to breastfeed, I can only help the patient." "That's great you both want to breastfeed, but only one will be able to lactate."

"It's not uncommon for both mothers to breastfeed. I will get you in touch with a lactation consultant to help."

A patient is in the office during the second trimester of pregnancy. The patient is concerned that her husband stated that he never fantasized about becoming a father as a child. What is the appropriate nursing response? "Men often do not fantasize about fatherhood as children." "He will probably not be a good father." "He will come around eventually." "That is very unusual, and counseling might be helpful."

"Men often do not fantasize about fatherhood as children."

A postpartum client asks the nurse when she can expect to get her period again. What is the correct response by the nurse? "Your period will return when you stop breastfeeding." "Because you are breastfeeding, you can expect to get your period 7 to 9 weeks post birth." "Return of your period depends on how long and how much you breastfeed." "Most women get their period within 10 weeks of delivery."

"Return of your period depends on how long and how much you breastfeed."

A nurse is caring for a client 24 hours post-delivery. What information is important for the postpartum nurse to include in this client's discharge teaching? Select all that apply. "Rise slowly to a standing position and be sure to sit down if you feel dizzy or faint." "You can resume sexual activity as soon as you feel up for it." "Drink plenty of water daily." "Resting when the baby is napping and enlisting help from family is important for breastfeeding and healing." "Sit down if you feel dizzy or faint."

"Rise slowly to a standing position and be sure to sit down if you feel dizzy or faint." "Drink plenty of water daily." "Resting when the baby is napping and enlisting help from family is important for breastfeeding and healing." "Sit down if you feel dizzy or faint."

A postpartum client asks the nurse why her temperature is slightly elevated. What is the correct response from the nurse? Select all that apply. "Youhadafeverduringlaborandtheantibioticshavenotstartedworkingyet." "The hard work of labor can cause your temperature to increase." "It is common for women to experience mild temperature elevation after giving birth." "Your body is going through a lot of hormonal changes right now, which can increase your temperature." "Do you feel hot? I will get you some Tylenol."

"The hard work of labor can cause your temperature to increase." "It is common for women to experience mild temperature elevation after giving birth." "Your body is going through a lot of hormonal changes right now, which can increase your temperature."

A G4P4004 client who is 6 hours post delivery is complaining of severe cramp-like uterine pains. What is a therapeutic nursing response? "The cramping should go away when you start breastfeeding." "The pains are caused by your uterus contracting and should get better in a few days." "This is your fourth baby, so you should be used to this by now." "The contractions will subside over the next 6 weeks as your uterus goes back to its normal size."

"The pains are caused by your uterus contracting and should get better in a few days."

When educating a non-breastfeeding primiparous client, what information is important for the nurse to include? Select all that apply. "Wear a supportive bra or sports bra 24 hours a day." "If your breasts become engorged, you should pump to relieve the pressure." "Do not apply ice packs to the breasts because it will stimulate milk production." "You can take an analgesic for pain." "You may experience milk leakage for the first 1 to 2 weeks."

"Wear a supportive bra or sports bra 24 hours a day." "You can take an analgesic for pain."

The nurse has just helped a first-time mom into the shower and notes the father awkwardly holding the infant. He states, "I'm so afraid I'm going to do something to hurt the baby." Which of the following are appropriate responses by the nurse? Select all that apply. "Would you like me to show you how to hold the baby so you are both comfortable?" "How is your relationship with your father?" "Please place the infant in the bassinet if you aren't comfortable holding him." "Would you like me to show you how to change his diaper and then swaddle him?" "I know you're nervous, but the baby isn't crying; you must be a natural!"

"Would you like me to show you how to hold the baby so you are both comfortable?" "Would you like me to show you how to change his diaper and then swaddle him?" "I know you're nervous, but the baby isn't crying; you must be a natural!"

A postpartum client asks the nurse if she needs to use contraception while breastfeeding. What is the most therapeutic response by the nurse? "Yes, because breastfeeding is not an effective contraceptive method." "You should not rely on breast feeding as a contraceptive." "It takes 9 to 10 weeks for your hormone levels to allow you to get pregnant." "That is a question for your doctor to answer."

"Yes, because breastfeeding is not an effective contraceptive method."

The postpartum nurse is educating a client about what to expect when she goes home. What information about diaphoresis is important to include in the teaching? Select all that apply. "Sweating occurs in the weeks after childbirth because of increased estrogen levels." "You might experience periods of profuse sweating." "This is your body's way of getting rid of extra fluid." "Wearing a cotton night gown will help with comfort." "If you experience profuse sweating you should take your temperature."

"You might experience periods of profuse sweating." "This is your body's way of getting rid of extra fluid." "Wearing a cotton night gown will help with comfort." "If you experience profuse sweating you should take your temperature."

A postpartum nurse is caring for multiple clients on the mother-baby unit. Which client should the nurse evaluate first? AG1P1 who gave birth 30 minutes ago and reports uncontrollable shaking A G6P5 who gave birth 6 hours ago and reports passing a softball-sized blood clot A G3P1 who is 2 days post-op cesarean section and reports sore nipples. AG2P1 who is 2 days post-op cesarean section and reports 6/10 abdominal pain

A G6P5 who gave birth 6 hours ago and reports passing a softball-sized blood clot

A nurse is caring for a client in the first hour following a vaginal delivery. What is the priority nursing intervention? Facilitate bonding between the mother and infant. Assess the fundus for location, position, and tone. Administer pain medications. Inspect the perineum for tearing.

Assess the fundus for location, position, and tone.

A postpartum nurse caring for a client who had a vaginal delivery 3 hours ago notices heavy lochia. What are the priority nursing interventions for this client? Select all that apply. Assess the position, tone, and location of the fundus. Massage a boggy uterus. Document the findings and reassess in 1 hour. Quantify blood loss. Instruct the client to void and reevaluate.

Assess the position, tone, and location of the fundus. Massage a boggy uterus. Quantify blood loss. Instruct the client to void and reevaluate.

A nurse is caring for a G2P2002 client in the initial hour after giving birth. What are the appropriate nursing interventions to be taken with this client? Select all that apply. Assess the uterus for location, position, and tone of fundus every 15 minutes. Titrate IV oxytocin infusion rate to uterine tone. Provide information regarding afterpains. Assess lochia for color, amount, and odor. Inspect the inside of the vagina for tearing.

Assess the uterus for location, position, and tone of fundus every 15 minutes. Titrate IV oxytocin infusion rate to uterine tone. Provide information regarding afterpains. Assess lochia for color, amount, and odor.

A nurse is caring for a G2P2002 client in the initial hour after giving birth. What are the appropriate nursing interventions to be taken with this client? Select all that apply. Assess the uterus for location, position, and tone of fundus every15 minutes. Titrate IV oxytocin infusion rate to uterine tone. Provide information regarding after pains. Assess lochia for color, amount, and odor. Inspect the inside of the vagina for tearing.

Assess the uterus for location, position, and tone of fundus every15 minutes. Titrate IV oxytocin infusion rate to uterine tone. Provide information regarding after pains. Assess lochia for color, amount, and odor.

The nurse educator on the postpartum unit is considering measures to help improve quantification of blood loss (QBL) measurement for the nurses. Which of the following measures would help with rapid assessment of QBL? Hold drills on straight catheter insertion. Create a laminated card that has the dry weights of the linens and disposable chux pads and peripads used on the unit and place it in every room. Schedule a team postpartum hemorrhage (PPH) drill for the unit including the nurses, unlicensed assistive personnel (UAPs), and medical residents. Create a laminated card with the contact information for the provider's lounge and the rapid response team and give to each nurse.

Create a laminated card that has the dry weights of the linens and disposable chux pads and peripads used on the unit and place it in every room.

The nurse is providing discharge teaching to a 20-year-old primiparous woman. In teaching the woman how to bathe and swaddle her infant, which method should the nurse use? Talk to the patient about how to bathe and swaddle. Give the patient written information to go through at home about bathing and swaddling her baby. Tell her that her mother will help her.

Demonstrate the proper technique for bathing and swaddling.

The nurse is caring for a blind patient who delivered 3 hours ago and was just transferred to the postpartum unit. What changes in care should the nurse consider for this patient? Select all that apply. Call child protective services for follow-up on the infant. Announce when you enter the room by addressing the patient by name and introducing yourself and anyone else in the room. Allow the patient to hold your elbow as you orient her to the room and describe the location of items in the room. Offer a blanket, bowl of water, and apat on the head for her seeing-eye dog to show caring. Describe the position of food on her plate and tray by using clock face positioning.

Describe the position of food on her plate and tray by using clock face positioning. Announce when you enter the room by addressing the patient by name and introducing yourself and anyone else in the room. Allow the patient to hold your elbow as you orient her to the room and describe the location of items in the room.

The nurse is caring for a primiparous woman who just delivered her child. Which action should the nurse take to adhere to the taking-in stage? Help the mother change the diaper. Give the patient time to reflect. Start to teach about her new mother body. Start to promote maternal independence.

Give the patient time to reflect.

The nurse is preparing information for a sibling class for children of parents who are pregnant with another child. While compiling the list of topics, what information would not be appropriate for the nurse to include? Feeling a sense of loss for the youngest child Allowing the child to feel the baby move during the pregnancy Allowing a visit to the hospital to hold the new infant Having the children stay with a grandparent for the first month after delivery

Having the children stay with a grandparent for the first month after delivery

The nurse is caring for a patient following the delivery of a 36-week infant due to maternal preeclampsia. The infant is stable and rooming-in with the mother. The nurse observes the mother demonstrating a slow response to the infant cues. What does the nurse attribute this slow response to? Magnesium sulfate infusion Increased blood pressure Hyperactive reflexes Subtle cues due to pre maturity

Magnesium sulfate infusion

A postpartum client complains of a headache that is worse when in an upright position that improves when supine. What is the priority nursing intervention? AdministerTylenol650mgPO. Notify the anesthesia provider. Encourage the client to lay down and rest. Increase IV fluids to promote rehydration.

Notify the anesthesia provider.

The nurse working in a pediatric office observes an adolescent mother yelling at a 6-month-old infant for dropping a pacifier. What is the appropriate nursing intervention? Call child protective services to report the mother. Offer anticipatory guidance on normal infant behavior and parent coping mechanisms. c. Mention it to the provider to ensure that it is documented in the medical record. d. Assume the mother is having a bad day and do nothing further.

Offer anticipatory guidance on normal infant behavior and parent coping mechanisms.

Anewnurseisassignedtocareforalesbiancoupleonthemother-babyunit. The nurse is heterosexual and has never cared for a homosexual patient before. What is important for the nurse to do before meeting the couple? Perform self-reflection of personal beliefs on homosexuality. Review the laws for same-sex parents. Ask the previous nurse if both parents are called "Mom." Discuss the care with the charge nurse for the shift.

Perform self-reflection of personal beliefs on homosexuality.

The nurse caring for a postpartum patient whose infant has been admitted to the neonatal intensive care unit (NICU) knows which of the following is a way to promote attachment between the mother and infant? Allowing the mother to have extended rest periods and visit the infant once daily Encouraging the mother to pump and dump her breast milk to maintain her supply because the infant will receive formula if it's admitted to the NICU Ensuring the father describes the infant to the mother if she is unable to go to the NICU Providing opportunities for the parents to care for their infant in the NICU

Providing opportunities for the parents to care for their infant in the NICU

A nurse is completing hospital orientation on the postpartum unit at a large hospital. During the orientation, the nurse participates in some classroom education on nursing theory. Which theorist would be included when discussing the early foundations of postpartum care? Reba Rubin Hildegard Peplau Ramona Mercer JeanWatson

Reba Rubin

Following an assessment of a mother and infant 4 hours after delivery, the nurse is going to document the stage the mother is in for maternal touch. The nurse observed the mother responding to the infant by using her hand to stroke the infant's head. What stage will the nurse document in the chart? Initial stage Second stage Third stage Final stage

Second stage

A nurse on the postpartum unit is instructing a new mother on diaper changes for the newborn. The patient is legally blind. What learning method would the nurse use for the patient? Demonstration with the infant on the warmer Video with return demonstration Handouts in braille with step-by-step instructions Self-demonstration by the mother with verbal cues

Self-demonstration by the mother with verbal cues

In preparing a childbirth education class, the nurse is planning to discuss the adaptations that family members experience because of a new infant in the home. What family members should the nurse include in addition to the parents? Select all that apply. Grandparents of the infant who live across the country and visit once a year Siblings of the parents who will be babysitting often Children of the parents Mother's cousin who lives in the same house as the baby Step-grandmother of the infant who visits often

Siblings of the parents who will be babysitting often Children of the parents Mother's cousin who lives in the same house as the baby Step-grandmother of the infant who visits often

The nurse is caring for a G1P1 patient who had an uncomplicated vaginal delivery 2 days ago. The patient is asking the nurse if she is doing the right things to take care of the infant, and also states she loves how doing skin-to-skin helps to calm the baby down. What other maternal behaviors would the nurse expect to see according to Rubin? Select all that apply. The mother has a very specific menu request. She is having feelings of anxiety about caring for her new family. She states she is loving these first few days of being a mom. She is over heard telling so me one on the phone that her yearly" girls trip" will be on hold for at least a few years now that she has a baby. She states she is feeling overwhelmed with all the care she needs to do to make sure the infant stays safe.

The mother has a very specific menu request. She states she is loving these first few days of being a mom. She states she is feeling overwhelmed with all the care she needs to do to make sure the infant stays safe.

A nurse is caring for a client who reports a spinal headache. What statements made by the client indicate an understanding of a postdural puncture headache? Select all that apply. a. "I'll need to lie down as much as possible to feel better." b. "My headache will get better when I stand up." c. "My head hurts because the fluid around mys pinal cord is decreased." d. "Dehydration caused my headache." e. "I should start to feel better in a few hours."

a. "I'll need to lie down as much as possible to feel better." c. "My head hurts because the fluid around mys pinal cord is decreased."

The postpartum nurse notices the patient holding the infant in the en-face position. What behavior does the nurse note in the chart about this behavior? a. Bonding b. Attachment c. Parenting d. Breastfeeding

a. Bonding

The parents of a newborn are ecstatic that the infant is easy to interact with the day after delivery. Later in that shift, the parents ask the nurse if the infant is okay, as the infant is not as responsive to stimuli at this time. What newborn state is the infant currently in? a. Deep sleep b. Quiet alert c. Drowsy d. Active alert

a. Deep sleep

A postpartum nurse is caring for a G3P2104 client immediately following vaginal delivery of a term neonate. The client states she's having chest pain, shortness of breath, and a cough, and has the following vital signs: blood pressure (BP) 110/73, heart rate (HR) 121, O2 saturation 90%, temp 99.1°F. The nurse recognizes the client could be experiencing what complication? a. Pulmonary embolism b. Postpartum hemorrhage(PPH) c. Preeclampsia d. Pulmonary edema

a. Pulmonary embolism

A postpartum nurse is caring for a client recovering from vaginal delivery of a term neonate 24 hours ago. The client had an uncomplicated pregnancy and delivery. What is a priority assessment for this client? a. Assess the breasts for signs of mastitis. b. Assess the calf and groin areas for tenderness, edema, and warmth. c. Assess the nipples for cracks and bruising. d. Assess the lower extremities for mild swelling.

b. Assess the calf and groin areas for tenderness, edema, and warmth.

A postpartum nurse is caring for a G1P1 client 24 hours post-vaginal delivery. What is the priority action for the nurse when preparing to assess for uterine involution? a. Administer zolpidem 5mg PO. b. Cluster nursing care, such as assessments and interventions. c. Encourage the woman to sleep when the baby sleeps. d. Remind her being tired is apart of motherhood she will need to get used to. e. Medicate for pain as per orders.

b. Cluster nursing care, such as assessments and interventions. c. Encourage the woman to sleep when the baby sleeps. e. Medicate for pain as per orders.

The nurse understands that different factors influence role transitions for new parents. Which of these factors are included? Select all that apply. a. Living on their own b. How they were parented c. Strength of the relationship between partners d. Education e. Finances

b. How they were parented c. Strength of the relationship between partners d. Education e. Finances

A nurse is caring for a client 6 hours post-vaginal delivery of a term neonate. She notes a white blood cell (WBC) count of 20,000/mm. What is the priority nursing intervention for this client? a. Notify the physician or midwife. b. Interpret as a normal finding. c. Administer Tylenol 1,000 mg PO.d. Order a repeat complete blood count (CBC) for the next morning.

b. Interpret as a normal finding.

A visiting nurse performing a well check-up at home for a client 5 days postdelivery asks the client about her lochia. The client states she has brown vaginal discharge. How should the nurse document this finding in the electronic health record (EHR)? a. Lochiarubra b. Lochia serosa c. Lochia alba d. Brown vaginal discharge

b. Lochia serosa

The parents of a newborn are ecstatic that the infant is easy to interact with the day after delivery. The nurse takes this opportunity to discuss infant alert states. What knowledge related to infant states will the nurse base the appropriate response on? a. Deep sleep b. Quiet alert c. Drowsy d. Active alert

b. Quiet alert

The postpartum nurse is educating a client who is receiving the measles, mumps, and rubella (MMR) vaccine. What statement made by the client indicates the need for further teaching? a. "My arm might be sore where I was given a shot." b. "I will avoid pregnancy for 4 weeks." c. "I will need to receive this vaccine again during my next pregnancy." d. "I am being vaccinated against German measles."

c. "I will need to receive this vaccine again during my next pregnancy."

The postpartum nurse is caring for a client with an anterior laceration following the vaginal delivery of a 9 lb infant. What information is a priority for the nurse to include in her teaching? a. "You might have difficulty with bowel movements because of the tear." b. "Make sure you take a stools often er and laxative at home." c. "You may experience difficulty with urination because of swelling." d. "You will probably experience mild pain for a few days."

c. "You may experience difficulty with urination because of swelling."

The phone triage nurse at an obstetrical (OB) office receives a call from a patient who delivered a healthy infant 1 week ago. The patient states that she is irritable and crying easily. What postpartum concern does the nurse educate the patient on? Postpartum blues Postpartum depression Postpartum psychosis Premenstrual syndrome

postpartum blues

During a morning assessment of a 15-hour-old infant, the nurse asks the mother, "Are you ready to breastfeed? Your baby is hungry!" The infant is most likely in what behavioral state for the nurse to make this statement? a. Light sleep b. Crying c. Active alert d. Drowsy

c. Active alert

Thenurseiscaringforapatientonthepostpartumunit.Thepatientandthe father of the infant are separated. The father states that he "plans to be involved with the baby, because I know it's important for the baby to have both parents involved as she grows." What term does the nurse use to identify the concept the father is describing? a. Marriage b. Joint custody c. Co-parenting d. Cohabitating

c. Co-parenting

The nurse is reviewing discharge instructions and discussing contraceptives with a multiparous couple who have a 2-day-old infant. Based on the client's history and assessment, which contraception should the nurse suggest to the couple and request from the provider? Select all that apply. a. Vasectomy b. Condoms c. Copper IUD d. Contraceptive patch

c. Copper IUD

A G6P5015 client who is 24-hours post-vaginal delivery reports severe cramp-like uterine pain. What is the priority nursing intervention for this client? a. Document the pain score in the electronic medical record(EMR). b. Assess the perineum for a vaginal hematoma. c. Encourage warm packs to the abdomen and provide an on steroidal anti-inflammatory drug (NSAID) such as ibuprofen. d. Notify the health-care provider STAT.

c. Encourage warm packs to the abdomen and provide an on steroidal anti-inflammatory drug (NSAID) such as ibuprofen.

A nurse is caring for a client who gave birth 30 minutes ago. Upon fundal assessment, the nurse notes moderate vaginal bleeding and a boggy uterus that does not respond to fundal massage. What is the priority nursing action? a. Continue fundal massage. b. Document the findings and reassess in 5 to 10 minutes. c. Increase IV oxytocin rate. d. Administer misoprostol 600 mg rectally.

c. Increase IV oxytocin rate.

Which of the following is one of the expectations by fathers for their role in parenting? New fathers expected to rely on their own fathers for support. New fathers took the role lightly, stating they only needed to provide financial support. c. New fathers were preparing more to parent their infant when it becomes a toddler and beyond. d. New fathers were thankful their partners were life coaches for their children.

c. New fathers were preparing more to parent their infant when it becomes a toddler and beyond.

The partner of a patient approaches the nurse 12 hours after the delivery of their healthy baby girl. The partner expresses concern that the patient appears indecisive and challenged to make even a simple decision. What phase does the nurse explain that this finding is attributed to? a. Taking-hold b. Taking-ground c. Taking-in d. Taking-rest

c. Taking-in