15 questions from powerpoint presentations
7. A mother, G6 P6006, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis.
Answer: 2 Rationale: The client should be monitored carefully for signs of postpartum hemorrhage. 3. This client is not especially at high risk for infection. 4. This client is not especially at high risk
3. A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. I will limit breastfeeding to 5 minutes per breast. B. I will not breastfeed if i start to have flu-like symptoms. C. I will shop for an underwire nursing bra today. D. I will avoid any of my family members who are ill.
Answer: D Rationale: The client should avoid ill family members to decrease the risk of mastitis. While the causative agent of mastitis tends to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis.
5. 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? A. "I should breast-feed every 2 to 3 hours." B. "I should change the breast pads frequently." C. "I should wash my hands well before breast-feeding." D. "I should wash my nipples daily with soap and water."
Answer: D Rationale: Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of handwashing and that she should breast-feed every 2 to 3 hours.
8. A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider about: 1. Bleeding that becomes lighter each day 2. Clots the size of golf balls 3. Saturating a pad in an hour 4. Lochia that lasts longer than 1 week
Answer: 3 Rationale: A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum
10. A multiparous client visits the urgent care center 5 days after a vaginal birth, experiencing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, "Why am I continuing to bleed like this?" The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following? 1. Uterine atony 2. Cervical lacerations 3. Vaginal lacerations 4. Retained placental fragments
Answer: 4 Rationale: The most likely cause of delayed postpartum hemorrhage is retained placental fragments. The client may be scheduled for a dilatation and curettage to remove remaining placental fragments. Uterine atony, cervical lacerations, and vaginal lacerations are commonly associated with early, not late, postpartum hemorrhage
9. A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which of the following? 1. Trauma during labor and birth. 2. Moderate fundal massage after birth. 3. Lengthy and prolonged second stage of labor. 4. Overdistention of the uterus from hydramnios."
Answer: 4 Rationale: The most likely cause of this client's uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and birth can also contribute to uterine atony during the postpartum period. Trauma during labor and birth is not a likely cause. In addition, no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps to contract the uterus, not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean birth for breech presentation. Therefore, it is unlikely that she had a long labor.
6. A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? A. Urine output 200 mL for the past 8 hours. B. Weight decrease of 2 pounds since delivery. C. Drop in hematocrit of 2% since admission. D. Pulse rate of 68 beats per minute
Answer: A Rationales: A. This output is below the accepted minimum for 8 hours. B. This weight decrease following delivery is within normal limits. C. A 2% drop in hematocrit is within normal limits. D. This pulse rate is within normal limits.
13. On the third day postpartum, which temperature is internationally defined as a postpartal infection? a) 99.6°F (37.5°C) b)100.4°F (38°C) c)102.4°F (39.1°C) d)104.2°F (40.1°C)
Answer: B Rationale: A temperature over 100.4°F (38°C) past the first day postpartum is suggestive of infection. An oral temperature of 100.4° F or 38° C or higher on any two of the first 10 days postpartum; or 101.6° F 38.7° C or higher during the first
12. A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? a) A client who experienced a precipitous labor less than 3 hrs. in duration. b) A client who had premature rupture of membranes and prolonged labor. c) A client who delivered a large for gestational age infant. d) A client who had a boggy uterus that was not well‑contracted.
Answer: B Rationale: Premature rupture of membranes with prolonged labor poses the greatest risk for developing a postpartum infection because the birth canal was open, allowing pathogens to enter. A precipitous labor places the client at risk for trauma and lacerations during delivery, but there is another client who is at greater risk for postpartum infection. Delivery of a large infant places the client at risk for a postpartum infection, but there is another client who is at greater risk. A boggy uterus that did not remain well‑contracted places the client at risk for a postpartum infection, but there is another client who is at greater risk
15. A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform? a) Cover the wound with sterile wet dressings. b) Notify the surgeon. c)Elevate the head of the client's bed slightly. d)Flex the client's knees.
Answer: B Rationale: The highest priority action is to notify the surgeon. After the surgeon has been notified, the nurse should stay with the patient while another staff member gathers supplies, including a suture removal kit and personal protective equipment as well as sterile saline solution and a large syringe. After the surgeon has been notified, the nurse should elevate the client's bed slightly. After the surgeon has been notified, the nurse should flex the client's knees slightly. TEST-TAKING TIP: Positioning of the client is important because the nurse wants to take as much stress off the incision as possible. If the surgeon is delayed and the dehiscence is significant the nurse must keep the intestines moist by placing sterile dressings that have been wetted with sterile saline over the area
4. A patient with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse? A. Organisms will be inactivated by gastric acid. B. Organisms that cause mastitis are not passed through the milk. C. The infant is not susceptible to the organisms that cause mastitis. D. The infant is protected from infection by immunoglobulins in the breast milk.
Answer: B Rationale: The organisms are localized in the breast tissue and are not excreted in the breast milk. The organism will not get into the infant's gastrointestinal system. Because of an immature immune system, infants are susceptible to many infections; however, this infection is in the breast tissue and is not excreted in the breast milk. The patient is just producing the immunoglobulin from this infection, so it is not available for the infant.
14. The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? a) Failed lactogenesis. b) Dysfunctional parenting. c)Wound dehiscence. d)Projectile vomiting.
Answer: C Rationale: This client is at high risk for wound dehiscence. Her wound healing may be impaired because of her diabetes and because of her obesity. There is nothing in this client's history that would indicate that she could not produce breast milk. There is nothing in this client's history that would indicate that she is at high risk for dysfunctional parenting. There is nothing in this client's history that would indicate that she is at high risk for projectile vomiting. TEST-TAKING TIP: The fact that this client is postoperative cesarean section is irrelevant. This question could have been written by a surgical nursing professor rather than a parent-child nursing professor. The important pieces of information needed to answer this question correctly are that this client is obese and a type 1 diabetic and that she has had surgery.
11. The nurse is caring for the postpartum client who has had an episiotomy. Which prescription would the nurse question if noted in the medical record? a) Apply analgesic spray as prescribed. b) Check the episiotomy site once per shift. c) Provide warm packs during the first 24 hours. d) Instruct the client in the procedure for cleansing the perineum.
Answer: C Rationale: When caring for a client who has had an episiotomy, the nurse would question a prescription that states to provide warm packs during the first 24 hours. Ice packs must be provided during this time to assist with decreasing pain and inflammation. The use of heat would increase inflammation in the area. Application of analgesic spray, checking of the episiotomy site once per shift, and instructing the client in the procedure for cleansing the perineum are all indicated.
A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis? A. I will wear an underwire bra to provide support when my milk comes in. B. I will apply petroleum jelly if my nipples become cracked. C. I will apply warm compresses to my breasts twice a day. D. I should avoid waiting too long between feedings.
Answer: D Rationale: Mastitis is an inflammation or infection of the breast. Risk factors include insufficient emptying of the breasts during breastfeeding, stress, illness, poor nutrition, and fatigue.
2. A nurse is teaching a client who is breastfeeding about strategies for preventing mastitis. Which of the following instructions should the nurse include? A. Take an herbal galactagogue B. Gradually increase the time between feedings. C. Wear an underwire bra. D. Use your finger to release suction after feeding.
Answer: D Rationale: Releasing the newborn's grasp on the nipple with a finger before removing the newborn from the breast helps prevent injury to the nipples, which can lead to mastitis.
