Postpartum NCLEX Style Questions
A nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which of the following signs, if noted, would be an early sign of excessive blood loss? A. A temperature of 100.4 F B. A blood pressure change from 130/88 to 124/80mmHg C. An increase in the pulse rate from 88 to 102 D. An increase in the RR from 18 to 22 breaths/min
C. During the fourth stage of labor vitals should be checked every 15 min during the first hour. An increasing in pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure decreases as the blood volume diminishes but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight increase in temperature is normal immediately postpartum. The RR is slightly increased from normal but not significant in this case.
A nurse is performing an assessment on a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints the nurse specifically checks the client's... A. Episiotomy for drainage B. Rectum for hemorrhoids C. Vulva for a hematoma D. Vagina for lacerations
C. Hematoma is suspected when the client reports pain or pressure in the vulvar area. Massive hemorrhage into the tissues can occur, resulting in hypovolemia and shock; therefore the clients complaints must be assessed so that interventions can begin immediately.
A nurse assigned to care for a postpartum client plans to promote parental-infant bonding by encouraging the parents to: A. Use a low-pitched voice to speak to the infant B. Allow the nursing staff to assume the infant care during hospitalization so they may rest C. Hold and cuddle the infant closely D. Allow the infant to sleep in the parental bed between the parents
C. Holding the infant close so that body warmth can be felt initiates a positive experience for the parent. It is also self-quieting and consoles the infant. The use of a high-pitched voice and participating in infant care promote parental-infant attachment. Infants should not be allowed to sleep between the parents, not only because of the danger of suffocation but also because the parent's will require meaningful rest and time to be alone as a couple.
A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as: A. Scant B. Light C. Heavy D. Excessive
C. Scant= <1 inch on pad in 1 hour Light = <4 inches on pad in 1 hour Moderate= <6 inches on pad in 1 hour Heavy= Saturated pad in 1 hour Excessive= Saturated pad in 15 minutes
A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the nurse include? A. The diet should include additional fluids B. Prenatal vitamins should be discontinued C. Soap should be used to cleanse the breasts. D. Birth control measures are unnecessary while breast-feeding.
A. A diet for a breast-feeding patient should include additional fluids. Prenatal vitamins should be taken as prescribed and soap should not be used on the breast because it removes natural oils which increases the chance of cracked nipples. Breast-feeding is not a sole method of contraception, so birth control measures should be resumed.
A nurse provides instructions to a new mother who is about to breast-feed her newborn infant. The nurse observes the new mother as she breast-feeds fo the first time and intervenes if the new mother: A. Turns the newborn infant on his side, facing the mother B. Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth C. Draws the newborn the rest of the way onto the breast when the newborn opens his mouth D. Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast.
B
Methylergonovine (Methergine) is prescribed for a woman who has just delivered a healthy newborn infant. The priority assessment before administering the medication is to check the clients: A. Lochia B. Uterine tone C. Blood pressure D. Deep tendon reflexes
C. A priority assessment before the administration of Methergine is blood pressure. Methergine is contraindicated in hypertension and must be administered cautiously in the presence of elevated blood pressure. The physician should be notified if hypertension is present. Options A and B are general components of postpartum assessment and nonspecific to the prescribed medication in this case. Option D is related to the administration of magnesium sulfate.
A nurse has provided discharge instructions to a client who delivered a healthy infant by cesarean delivery. Which statement made by the client indicates a need for further instructions? A. "I will begin abdominal exercises immediately." B. " I will notify the physician if I develop a fever." C. "I will turn on my side and push up with my arms to get out of bed." D. " I will lift nothing heavier than the newborn infant for at least 2 weeks."
A. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3-4 weeks postoperatively to allow for healing of the incision and approval from physician. Options B, C, and D are appropriate instructions for the client after a cesarean delivery.
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. A nurse instructs the client regarding measures to take for the treatment of the infection. Which of the following statements, if made by the client, would indicate a need for further instructions? A. "The prescribed medication must be taken until it is finished." B. "My fluid intake should be increased to at least 3000ml/day" C. "I need to urinate frequently throughout the day." D. "Foods and fluids that will increase urine alkalinity should be consumed"
D. A client with a UTI should be encouraged to take the medication for the entire length of time it is prescribed. The client should also be instructed to drink at least 3000ml/day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that increase ACIDITY of the urine should be encouraged.
A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list? A. Wear a supportive bra B. Rest during the acute phase C. Maintain a fluid intake of at least 3000 ml D Continue to breast-feed if the breasts are not too sore. E. Take the prescribed antibiotics until the soreness subsides. F. Avoid decompression of the breasts by breast-feeding or breast pump.
A, B, C, D Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000ml/day (if not contraindicated), taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken UNTIL THE COMPLETE PRESCRIBED COURSE IS FINISHED. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. CONTINUED DECOMPRESSION of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.
A second-day postpartum client with diabetes mellitus has scant lochia with a foul odor and a temperature of 101.6 degrees F. The physician suspects infection and writes orders to treat the client. Which of the following orders written by the physician would the nurse complete first? A. Obtain culture and sensitivity of lochia and urine B. Administer Ceftriaxone (Rocephin) C. Check the client's temperature D. Increase the intake of oral fluids.
A. Culture and sensitivity results should be obtained before any antibiotic therapy is begun to avoid masking the microorganisms identified in the culture. Options B and D are standard parts of therapy for this type of infection but are not completed first. Although the client's temperature is monitored, checking the temperature is not the first action.The data in the question indicate that the temperature has already been checked.
It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? A. At the umbilicus B. One fingerbreadth below the umbilicus C. Two fingerbreadth above the umbilicus D. Two fingerbreadth below the umbilicus
A. The term involution is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its pre-pregnant state. Immediately following delivery of the placenta the uterus contracts to the size of a large grapefruit The fundus is situated into the midline between the symphysis pubis and the umbilicus. Within 6 to 12 hour after birth the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one fingerbreadth on each succeeding day.
A postpartum client is diagnosed with cystitis .The nurse plans for which priority nursing intervention in the care of the client? A. Providing Sitz baths B. Encouraging fluid intake C. Placing ice on the perineum D. Monitoring hemoglobin and hematocrit levels.
B. Cystitis is an infection of the bladder. The client should consume 3000ml/day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. H&H would be monitored with hemorrhage.
A nurse is evaluating the mother-infant bonding process during the postpartum period. An indication of a maladaptive interaction would be if the mother: A. Expressed discomfort with the role of motherhood B. Encouraged the nurse to feed the baby because she continues to be too tired C. Showed that she was willing to learn how to care for the umbilical cord D. Talked to the baby
B. An indication of a maladaptive interaction is refusal to interact with or care for the infant. Options C and D identify situations in which the mother plans to or is demonstrating interaction with the infant. Expressing discomfort with the role of motherhood is not maladaptive.
A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? A. Infection B. Hemorrhage C. Chronic hypertension D. Disseminated intravascular coagulation
B. In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options A, C, and D are not risks that are related specifically to placenta previa.
After a precipitous delivery, a nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse should do which of the following to help the woman process what has happened? A. Encourage the mother to breast-feed soon after birth. B. Support the mother in her reaction to the newborn infant. C. Tell the mother that it is important to hold the newborn infant. D. Document a complete account of the mother's reaction on the birth record.
B. Precipitous labor is labor that lasts less than 3 hours. Women who have experienced precipitous labor often describe the feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened the best option is to support the client in her reaction to the newborn infant. Options A, C, and D do not acknowledge the client's feelings.
On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. The nurse's initial action is which of the following. A. Call the physician B. Assess the client's vital signs C. Gently massage the uterine fundus D. Administer a 300ml bolus of a 20 units/L Oxytocin(Pitocin) solution
C. The most frequent cause of excessive bleeding or hemorrhage after childbirth is uterine atony. A major intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. Options A, B and D may be necessary eventually but are not initial actions. The initial action is to alleviate the problem.
A discharge nurse is discussing mastitis with a postpartum client. Which of the following statements by the client would indicate a need for further instruction? A. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my healthcare provider." B. " I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings." C."If I develop a fever, chills, or body aches at any time after discharge I should stop breast feeding immediately." D. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis."
C. The mother should NOT discontinue breast-feeding
A nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago and notes that the mother's temperature is 102 F. The appropriate nursing action would be to: A. Notify the physician B. Remove the blanket from the client's bed C. Document the finding and recheck the temperature in 4 hours. D. Administer Acetaminophen (Tylenol) and recheck the temperature in 4 hours.
A. Vital signs are to return to normal within the first hour postpartum if no complication arise. If the temperature is greater than 2F above normal this may indicate infection, and the physician should be notified. Options B, C, and D are inaccurate nursing interventions for the client's temperature of 102F 2 hours following delivery.
A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client: A. Avoid rotating breast-feeding positions. B. Stop nursing until the nipples heal C. Substitute a bottle-feeding until the nipples heal. D. Position the infant with the ear, shoulder, and hip in straight alignment with the infant's stomach against the mother.
D. The nurse would suggest the mother position the infant in this manner. Rotating breast-feeding positions; breaking suction with the little finger; nursing frequently; begin feeding on the less sore nipple; not allowing the newborn to chew on the nipple or to sleep holding the nipple in the mouth and applying tea bags soaked in warm water to the nipple are also measures to alleviate nipple soreness.
