Postpartum NCLEX review
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action?
Increase hydration by encouraging oral fluids.
A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?
Encouraging fluid intake
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?
Hemorrhage
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2º F (37.8º C). What is the priority nursing action?
Increase hydration by encouraging oral fluids.
The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?
Massage the fundus until it is firm.
The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action?
Palpating the uterine fundus
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?
.Client pain level
Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care?
.Encourage the client to take pain medication as prescribed.
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?
"I will begin abdominal exercises immediately."
The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?
"We want to attend a support group."
A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.
2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs.
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?
3 days postpartum
The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?
4.Prepare an ice pack for application to the area.
The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?
A multiparous client who delivered a large baby after oxytocin induction
After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery?
Support the mother in her reaction to the newborn infant.
A client is diagnosed with placenta previa. The nurse plans care with the understanding that which is associated with placenta previa?
The placenta is implanted in the lower uterine segment.
A postpartum client is diagnosed with a urinary tract infection. Which measures should the nurse instruct the client to take regarding treatment and the prevention of a future infection?
Urinate frequently throughout the day.
The nurse visits at home a client who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply.
1.Wear a supportive bra between feedings. 2.Apply moist heat to both breasts for about 20 minutes before a feeding. 3.Feed the infant at least every 2 hours for 15 to 20 minutes on each side. 5.Massage the breasts gently during a feeding, from the outer areas to the nipples.
The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply.
1.Massaging the uterus 3.Assisting the woman to urinate 5.Checking for a distended bladder
Which instructions should the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply
1.Report a foul-smelling discharge. 2.Take a warm sitz baths 3 times a day. 4.Use warm water to rinse the perineum after elimination. 5.Wipe the perineum from front to back after voiding and defecation.
When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis?
2.Massage distended areas as the infant nurses.
A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.
2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs.
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?
4.The client with lochia that is red and has a foul-smelling odor
A type 1 diabetic mother delivered a 4400-gram newborn 3 hours ago. She has already initiated breast-feeding. What should the nurse plan to do to maintain euglycemia in this client?
Assess her blood glucose before administering any glucose-lowering medications.
The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?
Changes in vital signs
The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.
1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."
The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction?
3."If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately."
When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?
3.Notify the primary health care provider (PHCP).
The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?
Prepare an ice pack for application to the area.
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?
1.Client pain level
The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?
1.The diet should include additional fluids.
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?
"What can I do for you?"
The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.
1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily."
On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?
4."Foods and fluids that will increase urine alkalinity should be consumed."
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?
The client with lochia that is red and has a foul-smelling odor
The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis?
.Ask the client about pain in the calf area.
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?
"I should wash my nipples daily with soap and water."
The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions?
"If I notice any pain, redness, or swelling in my breasts, I should contact the primary health care provider."
The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
"You will need to bottle-feed your newborn."
At 10 days postpartum, a breast-feeding mother develops mastitis in her right breast. The nurse plans to instruct the client on which interventions? Select all that apply.
1.Using ice packs 2.Using analgesics 4.Wearing proper breast support 5.Completing the full course of prescribed antibiotics
The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.
1.Wear a supportive bra. 2.Rest during the acute phase. 3.Maintain a fluid intake of at least 3000 mL/day. 4.Continue to breast-feed if the breasts are not too sore.
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
An increase in the pulse rate from 88 to 102 beats per minute
The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take?
Assess for hypovolemia and notify the primary health care provider (PHCP).
On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?
Massage the fundus until it is firm.
A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure?
Breast-feed from the left breast and gently pump the right breast.
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?
Instruct the client to request help when getting out of bed.
When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?
Notify the obstetrician (OB).
The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?
The mother washes and dries her hands before and after self-care of her perineum and asks for a pair of gloves before feeding.
The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?
The diet should include additional fluids.
The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?
The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.