NCLEX postpartum

The nurse is assisting in developing a plan of care for a client preparing to breast-feed. In planning care, which factor is significant in teaching a client to breast-feed? 1.A positive nurse-client relationship 2.A client with previous breast-feeding experience 3.A health care provider that encourages clients to breast-feed 4.Brief separation of the infant and mother after birth to allow the mother to rest

1. A positive nurse-client relationship

A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breast-feed the baby as planned after delivery. The nurse makes which response to the client? 1."Breast-feeding is allowed once the baby has been vaccinated." 2."You will not be able to breast-feed the baby until 6 months after delivery." 3."Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby." 4."Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery."

1. Breast-feeding is allowed once the baby has been vaccinated

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? 1."I don't need birth control because I will be breastfeeding." 2."I need to increase my caloric intake by 500 calories a day." 3."I shouldn't use soap to wash my breasts because I will be breastfeeding." 4."I need to be sure that I increase my fluid intake and take my prenatal vitamins while breastfeeding."

1. I don't need birth control because I will be breastfeeding

The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding? 1.Is normal 2.Indicates that the client is hemorrhaging 3.Indicates the need to increase oral fluids 4.Indicates the need to contact the health care provider

1. Is normal

The nurse caring for a breast-feeding postpartum client plans to include avoidance of soaps on the nipples, frequent changing of breast pads, and intermittent exposure of nipples to the air. These interventions are implemented to prevent which complication? 1.Mastitis 2.Engorgement 3.Newborn colic 4.Let-down reflex

1. Mastitis

The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse? 1.Dehydration 2.A normal finding 3.Increased intracranial pressure 4.Decreased intracranial pressure

2. A normal finding

The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which should the nurse anticipate to be prescribed by the health care provider? 1.A repeat rubella titer in 2 weeks 2.Administration of a subcutaneous rubella virus vaccine 3.Administration of a subcutaneous rubella virus vaccine for the newborn 4.Counseling to the mother and informing the mother that this is a normal titer

2. Administration of a subcutaneous rubella virus vaccine

The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which? 1.Uterine atony 2.Bladder distention 3.Endometrial infection 4.Retained placental fragments

2. Bladder distention

A new mother attempting breast-feeding for the first time has developed mastitis. She states, "My breasts look terrible and I think that I will stop breast-feeding." The nurse plans care knowing that the client is concerned about which problem? 1.Infection 2.Body image 3.Newborn nutrition 4.Feelings of inadequacy

2. Body image

The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse should plan to perform which action when carrying out this prescription? 1.Use the dorsogluteal muscle. 2.Obtain written parental consent. 3.Select a 21-gauge, 1-inch needle. 4.Spread the skin under the injection site.

2. Obtain written parental consent

The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the health care provider? 1.Uterine cramping while breast-feeding 2.Pain, redness, or swelling in the breasts 3.Diaphoresis that occurs during the night 4.Existence of a serosanguineous vaginal drainage

2. Pain, redness, or swelling in the breasts

A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate? 1."The infection usually involves both breasts." 2."The infection can occur at any time during breast-feeding." 3."The infection usually is caused by wearing a supportive bra." 4."The infection is most common for women who have breast-fed in the past."

2. The infection can occur at any time during breast-feeding

The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding should indicate which accurate interpretation to the nurse? 1.This is a normal pulse rate following delivery. 2.This may be a sign of hemorrhage or shock. 3.This is a normal pulse rate following a loss of 500 mL of blood. 4.The mother is very excited about the delivery of the birth.

2. This may be a sign of hemorrhage or shock

The nurse is collecting initial data on a newborn in the delivery room. Which observation should the nurse expect to note when examining the umbilical cord of the newborn? 1.One artery and one vein 2.Two arteries and one vein 3.Two veins and one artery 4.Two arteries and two veins

2. Two arteries and one vein

Oxytocin (Pitocin) is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication? 1.Milk production 2.Uterine contractions 3.Increased urinary output 4.Decreased afterbirth pains

2. Uterine contractions

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount? 1.100 calories per day 2.300 calories per day 3.500 calories per day 4.1000 calories per day

3. 500 calories per day

The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign noted in the mother would indicate an early sign of excessive blood loss and shock? 1.A temperature of 100.4° F 2.A blood pressure change from 130/88 to 124/80 mm Hg 3.An increase in the pulse rate from 88 to 102 beats per minute 4.An increase in the respiratory rate from 18 to 22 breaths per minute

3. An increase in the pulse rate from 88 to 102 beats per minute

The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is important for the nurse to take at this time? 1.Assist the client to breast-feed. 2.Encourage food and fluid intake. 3.Check the uterine fundus and lochia. 4.Provide privacy for the parents and their newborn.

3. Check the uterine fundus and locia

The postpartum nurse is collecting data from a client who delivered a viable newborn 2 hours ago. The nurse palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should the nurse expect to note at this time? 1.Pink lochia 2.White lochia 3.Dark red lochia 4.Serosanguineous lochia

3. Dark red lochia

A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse should make which statement to the client? 1."Your newborn needs vitamin K to develop immunity." 2."The vitamin K will protect your newborn from becoming jaundiced." 3."Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 4."Newborns have sterile bowels. The vitamin K will colonize the bowel with the necessary bacteria."

3. Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding

After a precipitate delivery, the nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which action first to help the woman process what has happened? 1.Consider the cultural characteristics of the woman. 2.Encourage the mother to breast-feed soon after birth. 3.Support the mother no matter what her reaction is to the newborn. 4.Write a complete account of the parent's reaction on the birth record.

3. Support the mother no matter what her reaction is to the newborn

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make? 1.This is a normal expectation after episiotomy. 2.The mother should be allowed bathroom privileges only. 3.The bright red bleeding is abnormal and should be reported. 4.The perineal assessment should be performed more frequently.

3. The bright red bleeding is abnormal and should be reported

The nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmia neonatorum and gonococcal infection. The student correctly identifies which medication? 1.Neomycin 2.Penicillin 3.Silver nitrate 4.Erythromycin

4. Erythromycin

The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals? 1.Every hour for the first 2 hours and then every 4 hours 2.Every 30 minutes during the first hour and then every hour for the next 2 hours 3.Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4.Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours

4. Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours

The nurse has a prescription to give a dose of Rho(D) immune globulin (RhoGAM) to a client who has delivered an infant. The nurse understands that this medication will prevent the next infant from experiencing which complication? 1.Having Rh-positive blood 2.Developing perinatal infection 3.Experiencing high bilirubin levels 4.Being affected by Rh incompatibility

4. Being affected by Rh incompatibility

The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement by the client indicates a need for further teaching? 1."I need to take the antibiotics as prescribed." 2."I need to take warm sitz baths to promote healing." 3."I need to apply warm compresses to provide comfort." 4."I need to isolate my infant for 48 hours after the starting the antibiotics."

4. I need to isolate my infant for 48 hours after the starting the antibiotics

In formulating the plan of care, which problem is most important to address for a postpartum client who has expressed concerns about not knowing how to care for her newborn? 1.Lack of ability to cope 2.Presence of grieving in a dysfunctional way 3.Lack of self-esteem with regard to caring for the newborn 4.Lack of knowledge regarding ability to care for the newborn

4. Lack of knowledge regarding ability to care for the newborn

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? 1.The inverted uterus returning to normal 2.The gradual reversal of the uterine muscle into the abdominal cavity 3.The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4.The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1cm/day

The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client? 1.To stop breast-feeding 2.To avoid wearing a bra 3.To avoid taking analgesics 4.To complete the entire antibiotic regimen

4. To complete the entire antibiotic regimen

In most healthy newborns, blood glucose levels stabilize at _________ mg/dL during the first hours after birth:

50-60 mg/dL

What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? A. Apical heart rate of 90 beats/min, slightly irregular, when awake and active B. Acrocyanosis C. Harlequin color sign D. Weight loss representing 5% of the newborn's birth weight

A. Apical heart rate of 90 beats/min. slightly irregular, when awake and active

Which of these statements indicate the effect of breastfeeding on the family or society at large. (Select all that apply.) A. Breastfeeding requires fewer supplies and less cumbersome equipment. B. Breastfeeding saves families money. C. Breastfeeding costs employers in terms of time lost from work. D. Breastfeeding benefits the environment. E. Breastfeeding results in reduced annual health care costs.

A. Breastfeeding requires fewer supplies and less cumbersome equipment B. Breastfeeding saves families money D. Breastfeeding benefits the environment E. Breastfeeding results in reduced annual health care costs

The birth weight of a breastfed newborn was 8 lbs, 4 oz. On the third day the newborn's weight was 7 lbs, 12 oz. On the basis of this finding, the nurse should: A. Encourage the mother to continue breastfeeding since it is effective in meeting the newborn's nutrient and fluid needs. B. Suggest that the mother switch to bottle-feeding since the breastfeeding is ineffective in meeting newborn needs for fluid and nutrients. C. Notify the physician since the newborn is being poorly nourished. D. Refer the mother to a lactation consultant to improve her breastfeeding technique.

A. Encourage the mother to continue breastfeeding since it is effective in meeting the newborn's nutrient and fluid needs

At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________.

Apgar score of 9

The priority nursing intervention for a woman who suffered a perineal laceration is to: A. Apply a cold compress. B. Establish hemostasis. C. Administer analgesia. D. Administer a stool softener.

B. Establish hemostasis

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: A. Urinary tract infection. B. Excessive uterine bleeding. C. A ruptured bladder. D. Bladder wall atony.

B. Excessive uterine bleeding

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: A. Telling the mother not to worry since all breastfed babies have this type of stool. B. Explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. C. Asking the mother what she ate at her last meal. D. Suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.

B. Explaining to the mother that the stool is called meconium an is expected of all newborns for the first few bowel movements

When helping a woman cope with postpartum blues, the nurse should offer what appropriate suggestions? (Select all that apply.) A. The father should take over care of the baby, because postpartum blues are exclusively a female problem. B. Get plenty of rest. C. Plan to get out of the house occasionally. D. Asking for help will not foster independence. E. Use La Leche League or community mental health centers.

B. Get plenty of rest C. Plan to get out of the house occasionally

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

Vitamin K is given to the newborn to: A. Reduce bilirubin levels. B. Increase the production of red blood cells. C. Enhance ability of blood to clot. D. Stimulate the formation of surfactant.

C. Enhance ability of blood to clot

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

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: A. Birth injury. B. Hypocalcemia. C. Hypoglycemia. D. Seizures.

C. Hypoglycemia

Which postpartum infection is most often contracted by first-time mothers who are breastfeeding? A. Endometritis B. Wound infections C. Mastitis D. Urinary tract infections (UTIs)

C. Mastitis

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

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 or left foot E. Lochia rubra with foul odor

Postpartum women experience an increased risk for urinary tract infection. A prevention measure the nurse could teach the postpartum woman would be to: A. Acidify the urine by drinking three glasses of orange juice each day. B. Maintain a fluid intake of 1 to 2 L/day. C. Empty her bladder every 4 hours throughout the day. D. Perform perineal care on a regular basis.

D. Perform perineal care on a regular basis

Postbirth uterine/vaginal discharge, called lochia: A. Is similar to a light menstrual period for the first 6 to 12 hours. B. Is usually greater after cesarean births. C. Will usually decrease with ambulation and breastfeeding. D. Should smell like normal menstrual flow unless an infection is present.

D. Should smell like normal menstrual flow unless a infection is present

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A. Tell the woman she can rest after she feeds her baby. B. Recognize this as a behavior of the taking-hold stage. C. Record the behavior as ineffective maternal-newborn attachment. D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.

D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

The nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse should document which expected changes? 1.Slowed pulse rate and elevated blood pressure 2.Altered respiration and decreased blood pressure 3.Increased pulse rate and elevated blood pressure 4.Altered level of consciousness and rapid pulse rate

1. Slowed pulse rate and elevated blood pressure

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which would most likely indicate a hematoma? 1.Changes in vital signs 2.Signs of heavy bruising 3.Complaints of a tearing sensation 4.Complaints of lower abdominal discomfort

1. Changes in vital signs

The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care? 1.Set up a phototherapy unit. 2.Prepare for an exchange transfusion. 3.Ask about the newborn's blood type and direct Coombs. 4.Administer an injection of vitamin K to prevent isoimmunization.

3. Ask about the newborn's blood type and direct Coombs

The nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching? 1."I can resume sexual activity at any time." 2."I can expect red drainage for a few days." 3."Walking is an excellent form of exercise for me now." 4."I should drink an adequate amount of fluids every day."

1. I can resume sexual activity at any time

Which nursing actions would decrease the discomfort of an episiotomy? Select all that apply. 1.Performing sitz baths 2.Encouraging Kegel exercises 3.Administering oxytocin (Pitocin) 4.Applying ice packs to the perineum for the first 12 to 24 hours 5.Teaching how to perform perineal care after each voiding or bowel movement

1. Performing sitz bath 4. Applying ice packs to the perineum for the first 12 to 24 hours

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note? 1.Red 2.Pink 3.White 4.Serosanguineous

1. Red

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1.Rest during the acute phase. 2.Wear a supportive, nonunderwire bra. 3.Maintain a fluid intake of at least 3000 mL. 4.Continue to breastfeed if the breasts are not too sore. 5.Take the prescribed antibiotics until the soreness subsides. 6.Avoid decompression of the breasts by breastfeeding or breast pump

1. Rest during the acute phase 2. Wear a supportive, nonunderwire bra 3. Maintain a fluid intake of at least 3000 mL 4. Continue to breastfeed if the breasts are not too sore

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? 1.Tachypnea and retractions 2.Acrocyanosis and grunting 3.Hypotension and bradycardia 4.The presence of a barrel chest with acrocyanosis

1. Tachypnea and retractions

The nurse has reinforced instructions to a postpartum client who is hepatitis B positive how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure? 1.Washes and dries her hands before feeding 2.Requests that the window be closed before feeding 3.Holds the infant properly during feeding and burping 4.Tests the temperature of the formula before initiating feeding

1. Washes and dries her hands before feeding

A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note which uterine fundus position? 1.To the left of the abdomen 2.To the right of the abdomen 3.At the level of the umbilicus 4.Two fingerbreadths above the symphysis pubis

3. At the level of the umbilicus

The nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs? 1.Palpates for pedal pulses 2.Checks the calf areas for redness or swelling 3.Checks for the presence of pain when ambulating 4.Observes for the presence of a vaginal hematoma

2. Checks the calf areas for redness or swelling

The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test? 1.Serum insulin level 2.Heel stick blood glucose 3.Rh and ABO blood typing 4.Indirect and direct bilirubin levels

2. Heel stick blood glucose

Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression? 1.The mother is caring for the infant in a loving manner. 2.The mother constantly complains of tiredness and fatigue. 3.The mother demonstrates an interest in the surroundings. 4.The mother looks forward to visits from the father of the newborn.

2. The mother constantly complains of tiredness and fatigue

The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which? 1.A normal finding 2.The presence of infection 3.The need for increasing oral fluids 4.The need for increasing ambulation

2. The presence of infection

A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Which activity is a part of the method to accurately determine the amount of flow for documentation purposes? 1.Counting the number of pads used each day 2.Weighing the perineal pad before and after use 3.Estimating the extent of staining on a perineal pad 4.Tracking the number of times a day the pad is changed

2. Weighing the perineal pad before and after use

The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers? 1.If triple dye has been applied to the cord, it is not necessary to do anything else to it. 2.All that is necessary is to wash the cord with antibacterial soap, allowing it to air dry once a day. 3.Clean around the cord with plain water as needed until the cord falls off 4.Gently apply alcohol to the cord, being careful not to move the cord because it will cause the newborn pain.

3. Clean around the cord with plain water as needed until the cord falls off

After birth the nurse prevents hypothermia as a result of evaporation by performing which action? 1.Warming the crib pad 2.Closing the doors of the room 3.Drying the baby with a warm blanket 4.Turning on the overhead radiant warmer

3. Drying the baby with a warm blanket

The nurse is adding to a plan of care for a postpartum client. Which intervention would promote parent-infant bonding? 1.Support her decision to have the infant sleep in the parental bed. 2.Have the nursing staff care for the infant when she is frustrated. 3.Encourage her to hold the infant even when the infant is crying. 4.Suggest using a low-pitched voice to provide comfort to the infant.

3. Encourage her to hold the infant even when the infant is crying

A client delivers a viable neonate who is given APGAR scores of 8 and 9 at 1 and 5 minutes. How does the nurse characterize the neonate's physical condition? 1.Poor 2.Fair 3.Good 4.Critical

3. Good

The nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate? 1.Elevate the head of the bed. 2.Obtain a hemoglobin and hematocrit level. 3.Instruct the mother to request help when getting out of bed. 4.Inform the nursery room nurse to avoid bringing the newborn to the mother until the feelings of lightheadedness and dizziness have subsided.

3. Instruct the mother to request help when getting out of bed

While a client is holding and talking to her newborn immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior? 1.The client is likely to demonstrate malattachment. 2.The client is disappointed with the baby's gender. 3.The client is experiencing a normal response to birth. 4.The client is grieving over the loss of the pregnancy.

3. The client is experiencing a normal response to birth

A client had a cesarean delivery with a low transverse uterine incision. Which is the benefit of this type of incision? 1.It requires that a vertical skin incision be made. 2.It can be extended if a larger incision is needed. 3.It is the best choice with a placenta previa on the lower anterior uterine wall. 4.It allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.

4. It allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy

The nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The mother has been diagnosed with human immunodeficiency virus (HIV). Which is the appropriate method of feeding for this client? 1.Breast-feeding for 6 months 2.Breast-feeding for 9 months 3.Bottle-feeding with a fortified formula 4.Bottle-feeding with a tolerated formula

4. Bottle-feeding with a tolerated formula

The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. The nurse understands that this ointment is characterized by which description? 1.Administered at room temperature to prevent side effects 2.More irritating to the newborn's eyes than silver nitrate drops 3.Staining to the infant's skin and must be wiped off immediately 4.Effective in protecting the newborn from Neisseria gonorrhoeae and Chlamydia

4. Effective in protecting the newborn from Niesseria gonorrhoeae and chlamydia

The nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed which amount? 1.One pad a day 2.Two pads a day 3.Three pads a day 4.Eight pads a day

4. Eight pads a day

The nurse is reviewing the procedure for vitamin K injection in a newborn. Which information is included in the procedure? 1.Inject at a 45-degree angle. 2.Use a 22-gauge, 1-inch needle for the injection. 3.Do not massage the injection site after administration. 4.Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute.

4. Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute

The new breast-feeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother would indicate a need for further teaching? 1."I will wash my breasts gently with plain water." 2."I need to change my breast pads when they are wet." 3."When my breasts feel engorged, I will use a heat pack for the pain." 4."My left breast is sore, so I will offer only my right breast frequently for breast-feeding."

4. My left breast is sore, so I will offer only my right breast frequently for breast-feeding

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action? 1.Apply cool packs to the abdomen. 2.Continue to monitor the temperature. 3.Remove the blanket from the client's bed. 4.Notify the registered nurse, who will then contact the health care provider (HCP).

4. Notify the registered nurse, who will then contact the health care provider (HCP)

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse should give which response to the client? 1.Prevents cataracts in the neonate born to a woman who is susceptible to rubella 2.Protects the neonate's eyes from possible infections acquired while hospitalized 3.Minimizes the spread of microorganisms to the neonate from invasive procedures during labor 4.Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

4. Prevents ophtalmia neonatorum from occuring after delivery to a neonate born to a woman with an untreated gonoccoal infection

Oxytocin (Pitocin) is prescribed to be administered intravenously to a client after a cesarean delivery. The nurse understands that which is the action of the medication? 1.To minimize the possibility of uterine infection 2.To stimulate the production of estrogen postdelivery 3.To stimulate the production of progesterone for breast-feeding 4.To stimulate the uterus to contract, thus reducing possible blood loss

4. To stimulate the uterus to contract, thus reducing possible blood loss

The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which problem is most likely to occur during this stage? 1.Anxiety related to childbirth 2.Pain because of the process of labor or birth 3.Fatigue resulting from physical exertion during labor 4.Urinary retention caused by the loss of sensation to void and rapid bladder filling

4. Urinary retention caused by the loss of sensation to void and rapid bladder filling

As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures: (Select all that apply.) A.Prevent exposure to people with upper respiratory tract infections B. Keep the infant away from secondhand smoke C. Avoid loose bedding, waterbeds, and beanbag chairs D. Do not let the infant sleep on his or her back E. Keep a bulb suction available at home.

A. Prevent exposure to people with upper respiratory tract infections B. Keep the infant away from secondshake smoke C. Avoid loose bedding, waterbeds, and beanbag chairs E. Keep a bulb suction available at home

With regard to umbilical cord care, nurses should be aware that: A. The stump can easily become infected. B. A nurse noting bleeding from the vessels of the cord should immediately call for assistance. C. The cord clamp is removed at cord separation. D. The average cord separation time is 5 to 7 days.

A. The stump can easily become infected

The breasts of a bottle-feeding woman are engorged. The nurse should tell her to: A. Wear a snug, supportive bra. B. Allow warm water to soothe the breasts during a shower. C. Express milk from breasts occasionally to relieve discomfort. D. Place absorbent pads with plastic liners into her bra to absorb leakage.

A. Wear a snug, supportive bra

The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: A. Call the woman's primary health care provider B. Administer the standing order for an oxytocic C. Palpate the uterus and massage it to see if its boggy D. Assess maternal blood pressure and pulse for signs of hypovolemic shock

C. Palpate the uterus and massage it to see if its boggy

Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to: A. Place the newborn on the abdomen (prone) after feeding and for sleep. B. Avoid use of pacifiers. C. Use a rear-facing car seat. D. Use a crib with side rail slats that are no more than 3 inches apart.

C. Use a rear-facing car seat

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 the fundus

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should: A. Foster an active role in the baby's care. B. Provide time for the mother to reflect on the events of and her behavior during childbirth. C. Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. D. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs.

B. Provide time for the mother to reflect on events of and her behavior during childbirth

After completing a postpartum assessment on woman who delivered 20 hours ago, the nurse should report which assessment findings to the health care provider? (Select all that apply.) A. Temperature 100.0° F B. Pulse 110 beats/min C. Respiratory rate 12 breaths/min D. Blood pressure 125/78 E. Temperature 38° C

B. Pulse 110 beats/min E. Temperature 38 degrees C

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? A. Talks and coos to her son B. Seldom makes eye contact with her son C. Cuddles her son close to her D. Tells visitors how well her son is feeding

B. Seldom makes eye contact with her son

A newborn male, estimated to be 39 weeks of gestation, would exhibit: A. Extended posture when at rest. B. Testes descended into scrotum. C. Abundant lanugo over his entire body. D. Ability to move his elbow past his sternum.

B. Testes descended into scrotum

Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care? A. PPD symptoms are consistently severe. B. This syndrome affects only new mothers. C. PPD can easily go undetected. D. Only mental health professionals should teach new parents about this condition.

C. PPD can easily go undetected