Chapter 19: NCLEX practice questions

Baby-friendly hospitals mandate that infants be put to breast within what time frame after birth? A) 1 hour B) 30 minutes C) 2 hours D) 4 hours

*A) 1 hour* Rationale: Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth (BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after delivery. In many countries this is the norm; however, the Baby-Friendly Hospital Initiative (BFHI) mandates 1 hour. Ideally an infant should go no longer than 2 hours after delivery before being put to breast. This is much too long to wait to initiate breastfeeding, whether the hospital is baby-friendly or not.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: A) place her on a bedpan to empty her bladder. B) massage her fundus. C) call the physician. D) administer Methergine, 0.2 mg IM, which has been ordered prn.

*B) massage her fundus.* Rationale: There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.

A postpartum woman preparing for discharge asks the nurse about resuming sexual activity. Which information is appropriate to include in the patient teaching? (Select all that apply.) A) Do not perform Kegel exercises to decrease pelvic floor muscle healing time. B) If breastfeeding, sexual interest may be delayed. C) Fatigue may affect interest in sexual activity. D) Sexual activity can usually be safely resumed by 5 to 6 weeks after birth. E) Water-soluble lubrication may increase comfort. F) The female-on-top position may be more comfortable than other positions.

*C) Fatigue may affect interest in sexual activity.* *D) Sexual activity can usually be safely resumed by 5 to 6 weeks after birth.* *E) Water-soluble lubrication may increase comfort.* *F) The female-on-top position may be more comfortable than other positions.* Rationale: Kegel exercises are usually recommended and can strengthen the pubococcygeal muscle. Breastfeeding mothers often are interested in returning to sexual activity before nonbreastfeeding mothers. The amount of psychologic energy expended by the mother in child care activities may lead to fatigue and decreased interest in sexual activity. Most women can safely resume sexual activity by 5 to 6 weeks after birth. A water-soluble gel or jelly is recommended for lubrication. A position in which the mother has control of the depth of insertion of the penis, such as the female-on-top position may be more comfortable than other positions.

Which measure would be least effective in preventing postpartum hemorrhage? A) Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered B) Encourage the woman to void every 2 hours C) Massage the fundus every hour for the first 24 hours following birth D) Teach the woman the importance of rest and nutrition to enhance healing

*C) Massage the fundus every hour for the first 24 hours following birth* Rationale: Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: A) massage the fundus. B) administer Methergine, 0.2 mg PO, that has been ordered prn. C) assist the woman to empty her bladder. D) recognize this as an expected finding during the first 24 hours following birth.

*C) assist the woman to empty her bladder.* Rationale: A firm fundus should not be massaged since massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding, and an action is required.

Excessive blood loss after childbirth can have several causes; however, the most common is: A) vaginal or vulvar hematomas. B) unrepaired lacerations of the vagina or cervix. C) failure of the uterine muscle to contract firmly. D) retained placental fragments.

*C) failure of the uterine muscle to contract firmly.* Rationale: Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.

Which findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum? (Select all that apply.) A) Postural hypotension B) Temperature of 100.4° F C) Bradycardia—pulse rate of 55 beats/min D) Pain in left calf with dorsiflexion of left foot E) Lochia rubra with foul odor

*D) Pain in left calf with dorsiflexion of left foot* *E) Lochia rubra with foul odor* Rationale: Postural hypotension is an expected finding related to circulatory changes after birth A temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. These findings indicate a positive Homans' sign and are suggestive of thrombophlebitis and should be investigated. Lochia with odor may indicate infection.

Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects: A) bladder distention B) uterine atony C) constipation D) hematoma formation

*D) hematoma formation* Rationale: Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: A) begin an IV infusion of Ringer's lactate solution. B) assess the woman's vital signs. C) call the woman's primary health care provider. D) massage the woman's fundus.

*D) massage the woman's fundus.* Rationale: The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from an impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician should be notified after the nurse completes assessment of the woman. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A) uses soap and warm water to wash the vulva and perineum. B) washes from the symphysis pubis back to the episiotomy. C) changes her perineal pad every 2 to 3 hours. D) uses the peribottle to rinse upward into her vagina.

*D) uses the peribottle to rinse upward into her vagina.* Rationale: The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.