ob 5
Answer: 2 Explanation: 2. The first voiding should occur within 24 hours and first passage of stool within 48 hours.
18) A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurses best response? 1. I will call your pediatrician immediately. 2. Passage of the first stool within 48 hours is normal. 3. Your newborn might not have a stool until the third day. 4. Your newborn must be dehydrated.
Answer: 1 Explanation: 1. Severe anemia would predispose a client for thrombophlebitis.
26) Which of the following conditions would predispose a client for thrombophlebitis? 1. Severe anemia 2. Cesarean delivery 3. Anorexia 4. Hypocoagulability
Answer: 3 Explanation: 3. The Plastibell should fall off within 8 days. If it remains on after 8 days, the parents should consult with the newborns physician.
28) The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long? 1. 2 days 2. 10 days 3. 8 days 4. 14 days
Answer: 1, 2, 3, 5 Explanation: 1. During prolonged labor, the muscles relax because of prolonged time of contraction during labor. 2. During a difficult birth, the uterus is manipulated excessively, causing fatigue. 3. As the uterus is pushed up and usually to the right, pressure on a full bladder interferes with effective uterine contraction. 5. Inflammation and infection interfere with uterine muscles ability to contract effectively.
28) The nurse is teaching a prenatal class about postpartum changes. The nurse explains that factors that might interfere with uterine involution include which of the following? Select all that apply. 1. Prolonged labor 2. Difficult birth 3. Full bladder 4. Breastfeeding 5. Infection
Answer: 1 Explanation: 1. Methylergonovine maleate is the drug used for the prevention and control of postpartum hemorrhage.
3) The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus? 1. Methylergonovine maleate (Methergine) 2. Rh immune globulin (RhoGAM) 3. Terbutaline (Brethine) 4. Docusate (Colace)
Answer: 2 Explanation: 2. The nurse should explain the purpose and use of the sitz bath, anticipated effects, benefits, possible problems, and safety measures to prevent slipping or an injury from hot water. A call bell would be a safety measure.
4) A client is preparing to take a sitz bath for the first time. What will the nurse do? 1. Allow the client privacy during the sitz bath. 2. Place a call bell well within reach and check on the client frequently. 3. Discourage the client from taking a sitz bath. 4. Check on the client after the sitz bath.
Answer: 3 Explanation: 3. The nurse should discuss the importance of contraception during the early postpartum period and provide information on the advantages and disadvantages of different methods, including special considerations for breastfeeding mothers. The womans body needs adequate time to heal and recover from the stress of pregnancy and childbirth.
11) The breastfeeding client asks the nurse about appropriate contraception. What is the nurses best response? 1. Breastfeeding has many effects on sexual intercourse. 2. IUDs are easy to use and easy to insert prior to sexual intercourse. 3. Its possible to get pregnant before your menstrual period returns. Lets talk about some different options for contraception. 4. Breastfeeding hampers ovulation, so no contraception is needed.
Answer: 3 Explanation: 3. This statement indicates a stage of maternal role attainment in which the new mother feels comfortable enough to make her own decisions about parenting.
11) Which statement by a new mother 1 week postpartum indicates maternal role attainment? 1. I don't think I'll ever know what I'm doing. 2. This baby feels like a real stranger to me. 3. It works better for me to undress the baby and to nurse in the chair rather than the bed. 4. My sister took to mothering in no time. Why cant I?
Answer: 3 Explanation: 3. Soon after birth during the taking-in period, the woman tends to be passive and somewhat dependent. She follows suggestions, hesitates about making decisions, and is still rather preoccupied with her needs.
12) On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following? 1. The taking-hold phase 2. Postpartum hemorrhage 3. The taking-in period 4. Epidural anesthesia
Answer: 2 Explanation: 2. Women should be encouraged to limit the number of activities to prevent excessive fatigue, increase in lochia, and negative psychologic reactions, such as feeling overwhelmed. A regular exercise program including vigorous activities such as running, weight lifting, or competitive sports can usually be initiated after the 6-week postpartum examination or when approved by the clients physician/CNM.
12) The postpartum client expresses concern about getting back to her prepregnant shape, and asks the nurse when she will be able to run again. Which statement by the client indicates that teaching was effective? 1. I can start running in 2 weeks, and can breastfeed as soon as I am done. 2. I should see how my energy level is at home, and increase my activity slowly. 3. Running is not recommended for breastfeeding women. 4. If I am getting 8 hours of sleep per day, I can start running.
Answer: 2 Explanation: 2. A postpartum woman is at increased risk for developing urinary tract problems because of inhibited neural control of the bladder following the use of anesthetic agents.
13) A postpartum woman is at increased risk for developing urinary tract problems because of which of the following? 1. Decreased bladder capacity 2. Inhibited neural control of the bladder following the use of anesthetic agents 3. Increased bladder sensitivity 4. Abnormal postpartum diuresis
Answer: 1, 2, 3, 5 Explanation: 1. Adequate rest is essential to a smooth postpartum transition. The nurse can encourage rest by organizing activities to avoid frequent interruptions for the woman. 2. Mothers should be counseled to sleep when the baby sleeps. 3. Mothers should be counseled to delegate or postpone unnecessary chores and activities and to sleep when the baby sleeps. 5. Mothers should be counseled to utilize family and friends for support.
13) The nurse is teaching a new mother about ways to manage fatigue after she returns home. Which instructions should the nurse include? Select all that apply. 1. Take frequent rest periods. 2. Nap when the newborn is sleeping. 3. Avoid overdoing housework and unnecessary chores. Do not clean when infant is sleeping. 4. Avoid having others come to the house to do housework and interfere with rest. 5. Utilize friends and family to provide help and support, such as cooking a meal.
Answer: 4 Explanation: 4. To assess for thrombophlebitis, the nurse should have the woman stretch her legs out, with the knees slightly flexed and the legs relaxed. The nurse then grasps the foot and dorsiflexes it sharply. If pain is elicited, the nurse notifies the physician/CNM that the woman has a positive Homans sign. The pain is caused by inflammation of a vessel.
17) How does the nurse assess for Homans sign? 1. Extending the foot and inquiring about calf pain. 2. Extending the leg and inquiring about foot pain. 3. Flexing the knee and inquiring about thigh pain. 4. Dorsiflexing the foot and inquiring about calf pain.
Answer: 1, 2, 4 Explanation: 1. Mother-baby care is an important part of the family-centered care approach. 2. The nurse should encourage skin-to-skin contact between mother (or father) and baby to promote breastfeeding and bonding. 4. The mother-baby unit is conducive to an on-demand feeding schedule for both breastfeeding and formula-feeding infants.
17) What maternity unit policies promote postpartal family wellness and shared parenting? Select all that apply. 1. Mother-baby care or couplet care on the postpartum unit 2. Skin-to-skin contact between the mother and baby and the father and baby 3. Newborn kept in the nursery to allow mother to rest between feedings 4. On-demand feeding schedule for both breastfed and bottle-fed infants 5. Limited visiting hours for the father so that the mother can sleep as needed
Answer: 1, 2, 3 Explanation: 1. Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. 2. Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. 3. Women should be advised to avoid a sedentary lifestyle and to exercise as much as possible (walking is ideal).
18) A postpartal client recovering from deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client? Select all that apply. 1. Avoid crossing the legs. 2. Avoid prolonged standing or sitting. 3. Take frequent walks. 4. Take a daily aspirin dose of 650 mg. 5. Avoid long car trips.
Answer: 1, 2, 5 Explanation: 1. Currently, the couple is advised to abstain from intercourse until the episiotomy is healed and the lochia has stopped. 2. Because postpartum women often experience vaginal dryness due to hormonal changes, the use of a water-based lubrication, such as K-Y jelly or Astroglide, may initially be necessary during intercourse. 5. Maternal fatigue is often a significant factor limiting the resumption of sexual intercourse. While interest and desire vary, most couples resume sexual activity within 3 months.
18) What information should the nurse include when teaching the postpartal client and partner about resumption of sexual activity? Select all that apply. 1. Couples should be encouraged to abstain from intercourse until the episiotomy is healed and the lochial flow has stopped. 2. Postpartum women often experience vaginal dryness, and should be encouraged to use some kind of lubrication initially during intercourse. 3. Breastfeeding the newborn after intercourse can reduce the chance of milk spouting from the nipples. 4. Maternal changes in libido are usually indicative of psychological depression. 5. Maternal fatigue is often a significant factor limiting the resumption of sexual intercourse.
Answer: 1 Explanation: 1. If the mother finds that one area of her breast feels distended or lumpy, she can massage the lumpy area toward the nipple as the infant nurses.
19) The postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks whether there is something she can do to prevent mastitis this time. What would the best response of the nurse be? 1. Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple. 2. Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again. 3. Apply cabbage leaves to any areas that feel thickened or firm to relieve the swelling. 4. Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe.
Answer: 3 Explanation: 3. Using a special intravenous (IV) pump system, the woman presses a button to self-administer small doses of the medication as needed. For safety, the pump is preset with a time lockout so that the pump cannot deliver another dose until a specified time has elapsed. Women using PCA feel less anxious and have a greater sense of control with less dependence on the nursing staff.
19) What is the advantage of a client using a patient-controlled analgesia (PCA) following a cesarean birth? 1. The client receives a bolus of the analgesia when pressing the button. 2. The client experiences pain relief within 30 minutes. 3. The client feels a greater sense of control, and is less dependent on the nursing staff. 4. The client can deliver as many doses of the medication as needed.
Answer: 4 Explanation: 4. Emptying the bladder is the top priority.
22) The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringers solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action? 1. To massage the fundus vigorously 2. To assess the clients pain level 3. To increase the rate of the IV 4. To assist the client to the bathroom
Answer: 3 Explanation: 3. Clinical findings of metritis in the initial 24 to 36 hours postpartum tend to be related to group B streptococcus (GBS).
22) The client delivered her second child 1 day ago. The clients temperature is 101.4 F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics. The nurse provides education for the client and her partner. Which statement indicates that teaching has been effective?
Answer: 1 Explanation: 1. The mother tends to respond verbally to any sounds emitted by the newborn, such as cries, coughs, sneezes, and grunts. Responding hesitantly to infant cries might need further assessment to determine what the mother is feeling.
24) Which of the following behaviors noted in the postpartum client would require the nurse to assess further? 1. Responds hesitantly to infant cries. 2. Expresses satisfaction about the sex of the baby. 3. Friends and family visit the client and give advice. 4. Talks to and cuddles with the infant frequently.
Answer: 4 Explanation: 4. A gush of blood when a fundal massage is undertaken may occur because of normal pooling of blood in vagina when the woman lies down to rest or sleep.
25) The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurses best response? 1. We see this from time to time. Its not a big deal. 2. The gush is an indication that your fundus isnt contracting. 3. Dont worry. Ill make sure everything is fine. 4. Blood pooled in the vagina while you were in bed.
Answer: 1 Explanation: 1. The father, if he is involved, should be included as much as possible. If classes are offered in the hospital during the postpartum stay, the adolescent mother and father should be strongly encouraged to attend and participate.
26) The nurse is planning care for three newly delivered adolescents and their babies. What should the nurse keep in mind when planning their care? 1. The babys father should be encouraged to participate when the nurse is providing instruction. 2. A class for all the adolescents would decrease teaching effectiveness. 3. The schools that the adolescents attend will provide teaching on bathing. 4. Adolescents understand the danger signals in newborns.
Answer: 3 Explanation: 3. Tenseness of tissues that overlie the hematoma is characteristic of perineal hematomas.
26) The nurse suspects that a client has developed a perineal hematoma. What assessment findings would the nurse have detected to lead to this conclusion? 1. Facial petechiae 2. Large, soft hemorrhoids 3. Tense tissues with severe pain 4. Elevated temperature
Answer: 2 Explanation: 2. The postpartum blues consist of a transient period of depression that occurs during the first few days of puerperium. Symptoms may include mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown.
27) The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues? 1. I am so happy and blessed to have my new baby. 2. One minute Im laughing and the next Im crying. 3. My husband is helping out by changing the baby at night. 4. Breastfeeding is going quite well now that the engorgement is gone.
Answer: 4 Explanation: 4. Assessing the birth mothers preferences by respectfully asking questions and making no assumptions facilitates a more positive experience.
27) The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important? 1. Assign the client a room on the GYN surgical floor instead of on the postpartum floor. 2. Prepare to complete teaching in time for discharge at 24 hours post-delivery. 3. Make an effort not to bring up the topic of the baby, and discuss the mothers health instead. 4. Ask the client how much contact she would like with the baby, and whether she wants to feed it.
Answer: 2, 3, 4, 5 Explanation: 2. The mother who decides to relinquish her baby needs emotional support and validation of her loss. 3. The woman should decide whether to see and hold her baby and should have any special requests regarding the birth honored. 4. Perinatal nurses should be aware that relinquishing mothers are at risk for disenfranchised grief, in which they are unable to proceed through the grieving process and come to resolution with the loss. The nurse should acknowledge the womans loss and support her decision. 5. The amount of contact she chooses to have with her newborn should be respected.
28) The nurse is caring for a client who plans to relinquish her baby for adoption. The nurse would implement which approach to care? Select all that apply. 1. Encourage the client to see and hold her infant. 2. Encourage the client to express her emotions. 3. Respect any special requests for the birth. 4. Acknowledge the grieving process in the client. 5. Allow access to the infant, if the client requests it.
Answer: 1, 2, 4, 5 Explanation: 1. The use of sequential compression devices (SCDs) and early ambulation are essential to the prevention of deep vein thrombosis, especially if the client had a cesarean birth. 2. Ambulation should be encouraged as soon as possible to prevent pneumonia. 4. The new mother may need extra supervision and assistance when breastfeeding her baby to ensure newborn safety. 5. The obese client has needs similar to all postpartum client, but she needs special attention to prevent injury, respiratory complications, thromboembolic disease, and infection, for which she is at high risk.
35) The nurse is providing postpartum care to an obese client. As part of care for this client, the nurse should do which of the following? Select all that apply. 1. Apply sequential compression devices 2. Have the mother ambulate as early as possible 3. Encourage bottle-feeding over breastfeeding 4. Supervise breastfeeding 5. Instruct the client on signs of infection
Answer: 3, 4 Explanation: 3. Attachment behaviors include cuddling, soothing, and calling the baby by name. 4. Attachment behaviors include holding the baby in the en face position.
38) The nurse is preparing a class for mothers and their partners who have just recently delivered. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept? Select all that apply. 1. We should avoid holding the baby too much. 2. Looking directly into the babys eyes might frighten him. 3. Talking to the baby is good because hell recognize our voices. 4. Holding the baby so we have direct face-to-face contact is good. 5. We should only touch the baby with our fingertips for the first month.
Answer: 1, 4, 5 Explanation: 1. Face-to-face contact and eye contact indicates that the mother is attracted to the infant and is attending to the infants behavior. 4. The ability to point out family traits shows that she is pleased with the babys appearance and recognizes the infant as belonging to the family unit. 5. Showing pleasure with the infants appearance and sex indicates bonding is occurring.
39) Which factors would the nurse observe that would indicate a new mothers early attachment to the newborn? Select all that apply. 1. Face-to-face contact and eye contact 2. Failure to choose a name for the baby 3. Decreased interest in the infants cues 4. Pointing out familial traits of the newborn 5. Displaying satisfaction with the infants sex
Answer: 1 Explanation: 1. Encouraging sitz baths is the correct approach because moist heat decreases inflammation and provides for comfort.
4) A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate? 1. Encourage sitz baths. 2. Position the client in the supine position. 3. Avoid stool softeners. 4. Decrease fluid intake.
Answer: 4 Explanation: 4. These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest, elevation of the affected limb, analgesics, and use of elastic support hose.
7) A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action? 1. That the client would be encouraged to ambulate freely 2. That the client would be given aspirin 650 mg by mouth 3. That the client would be given Methergine IM 4. That the client would be placed on bed rest
Answer: 3 Explanation: 3. Applying cold packs to the breasts relieves discomfort and helps suppress lactation.
8) On the 3rd day postpartum, a client who is not breastfeeding experiences engorgement. To relieve her discomfort, the nurse should encourage the client to do which of the following? 1. Remove her bra 2. Apply heat to the breasts 3. Apply cold packs to the breasts 4. Use a breast pump to release the milk
Answer: 3 Explanation: 3. Treatment of mastitis includes frequent and complete emptying of the breasts.
8) The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following? 1. Wearing a tight-fitting bra 2. Limiting breastfeedings 3. Frequent breastfeedings 4. Restricting fluid intake
Answer: 4 Explanation: 4. The type, amount, and consistency of lochia determine the state of healing of the placental site, and a progressive color change from bright red at birth to dark red to pink to white or clear should be observed.
8) To assess the healing of the uterus at the placental site, what does the nurse assess? 1. Lab values 2. Blood pressure 3. Uterine size 4. Type, amount, and consistency of lochia
Answer: 3 Explanation: 3. Signs of mastitis include late-onset nipple pain, followed by shooting pain between feedings, often radiating to the chest wall. Eventually, the skin of the affected breast may become pink, flaking, and pruritic.
9) A postpartum client reports sharp, shooting pains in her nipple during breastfeeding and flaky, itchy skin on her breasts. Which of the following does the nurse suspect? 1. Nipple soreness 2. Engorgement 3. Mastitis 4. Letdown reflex
Answer: 1, 3, 4, 5 Explanation: 1. The nurse continues to assess the womans pain level and provide relief measures as needed. 3. Within the first 12 hours postoperatively, unless medically contraindicated, the woman should be assisted to dangle her legs on the side of the bed. 4. The woman is encouraged to cough and breathe deeply and to use incentive spirometry every 2 to 4 hours while awake for the first few days following cesarean birth. 5. The nurse should encourage the use of breathing, relaxation, and distraction techniques.
9) The nurse is caring for a client who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time? Select all that apply. 1. Administer analgesics as needed. 2. Encourage the client to ambulate to the bathroom to void. 3. Encourage leg exercises every 2 hours. 4. Encourage the client to cough and deep-breathe every 2 to 4 hours. 5. Encourage the use of breathing, relaxation, and distraction.
Answer: 3 Explanation: 3. Lochia rubra is dark red in color. It is present for the first 2 to 3 days postpartum. Lochia serosa is a pinkish color and it follows from about the 3rd to the 10th day.
9) The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement? 1. I should expect a lighter flow next week. 2. The flow will increase if I am too active. 3. My bleeding will remain red for about a month. 4. I will be able to use a pantiliner in a day or two.
Answer: 3 Explanation: 3. Asking this question allows the nurse to determine what the parents concerns are, then address them specifically.
1) The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? 1. Circumcision should be undertaken to prevent problems in the future. 2. Circumcision might decrease the childs risk of developing a urinary tract infection. 3. Circumcision can sometimes cause complications. What questions do you have? 4. Circumcision is painful, and should be avoided unless you are Jewish.
Answer: 1 Explanation: 1. Following birth, some women feel exhausted and in need of rest. Other women are euphoric and full of psychic energy, ready to retell their experience of birth repeatedly.
10) A client who delivered 2 hours ago tells the nurse that she is exhausted and feels guilty because her friends told her how euphoric they felt after giving birth. How should the nurse respond? 1. Everyone is different, and both responses are normal. 2. Most mothers do feel euphoria; I dont know why you dont. 3. Its good for me to know that because it might indicate a problem. 4. Let me bring your baby to the nursery so that you can rest.
Answer: 4 Explanation: 4. Nasal flaring and facial grimacing are signs of respiratory distress.
10) The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? 1. Neonatal jaundice 2. Neonatal hypothermia 3. Neonatal hyperthermia 4. Respiratory distress
Answer: 1, 3, 4 Explanation: 1. The nurse would remove the needle and massage the site with an alcohol swab. 3. Vitamin K is given intramuscularly in the vastus lateralis muscle. 4. Before injecting, the nurse must clean the newborns skin site for the injection thoroughly with a small alcohol swab.
11) A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply. 1. Gently massage the site after injection. 2. Use a 22-gauge, 1-inch needle. 3. Inject in the vastus lateralis muscle. 4. Cleanse the site with alcohol prior to injection. 5. Inject at a 45-degree angle.
Answer: 1, 2, 5 Explanation: 1. To maintain a healthy temperature in the newborn, keep the newborns clothing and bedding dry. 2. To maintain a healthy temperature in the newborn, reduce the newborns exposure to drafts. 5. To maintain a healthy temperature in the newborn, encourage the mother to snuggle with the newborn under blankets.
12) To maintain a healthy temperature in the newborn, which of the following actions should be taken? Select all that apply. 1. Keep the newborns clothing and bedding dry. 2. Reduce the newborns exposure to drafts. 3. Do not use the radiant warmer during procedures. 4. Do not wrap the newborn. 5. Encourage the mother to snuggle with the newborn under blankets.
Answer: 3 Explanation: 3. Nasal flaring is an indication of respiratory distress. The nurse must be immediately available to provide appropriate interventions for a newborn in distress.
13) The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? 1. 37-week male, respiratory rate 45 2. 8 pound 1 ounce female, pulse 150 3. Term male, nasal flaring 4. 4-hour-old female who has not voided
Answer: 2 Explanation: 2. The normal respiratory rate is 30-60 breaths/min; 68 breaths/min could represent a less-than-ideal transition.
14) The nurse assesses a sleeping 1-hour-old, 39-weeks-gestation newborn. The assessment data that would be of greatest concern would be which of the following? 1. Temperature 97.9F 2. Respirations 68 breaths/minute 3. Vital signs stable for only 2 hours 4. Heart rate 156 beats/min
Answer: 4 Explanation: 4. Women who have not sufficiently recovered from the effects of anesthesia and cannot void spontaneously are at risk for urinary retention after childbirth.
14) Which of the following is a risk factor for urinary retention after childbirth? 1. Multiparity 2. Precipitous labor 3. Unassisted childbirth 4. Not sufficiently recovering from the effects of anesthesia
Answer: 1 Explanation: 1. Cool baths will chill a newborn, and should not be given. Bathing under warm water is ideal.
15) A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? 1. A quick cool bath will help wake up my son for feedings. 2. I can check my sons temperature under his arm. 3. My baby should be dressed warmly, with a hat. 4. Cuddling my son will help to keep him warm.
Answer: 2 Explanation: 2. The nurse should be aware that standardized postpartum instructions, particularly those related to intercourse and contraception might need to be individualized and amended.
15) Which statement by a nursing student preparing to care for a postpartum lesbian mother would indicate the need for further teaching? 1. I cant let the client know Ive never worked with lesbian mothers. 2. I will have to adjust some of my discharge instruction for this mother. 3. I dont need to include the partner when I provide care and instruction. 4. Discharge teaching is exactly the same for lesbian mothers as for all others.
Answer: 1, 2, 5 Explanation: 1. Successful eye prophylaxis requires that the medication be instilled in the lower conjunctival sac of each eye. 2. After administration, the nurse massages the eyelid gently to distribute the ointment. 5. Eye prophylaxis medication can cause chemical conjunctivitis, which gives the newborn some discomfort and can interfere with the babys ability to focus on the parents faces.
16) The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Select all that apply. 1. The medication should be instilled in the lower conjunctival sac of each eye. 2. The eyelids should be massaged gently to distribute the ointment. 3. The medication must be given immediately after delivery. 4. The medication does not cause any discomfort to the infant. 5. The medication can interfere with the babys ability to focus.
Answer: 2 Explanation: 2. It is important to observe for the first voiding after a circumcision to evaluate for urinary obstruction related to penile injury and/or edema.
17) The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? 1. Keep the infant NPO for 4 hours following the procedure. 2. Observe for urine output. 3. Wrap dry gauze tightly around the penis. 4. Clean with cool water with each diaper change.
Answer: 2 Explanation: 2. Changing peri-pads frequently decreases skin contact with a moist medium that favors bacteria growth.
17) To prevent the spread of infection, the nurse teaches the postpartum client to do which of the following? 1. Address pain early 2. Change peri-pads frequently 3. Avoid overhydration 4. Report symptoms of uterine cramping
Answer: 2 Explanation: 2. This newborns weight loss is within normal limits. A weight loss of up to 10% for term newborns is considered within normal limits during the first week of life.
19) At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborns weight is which of the following? 1. Excessive 2. Within normal limits 3. Less than expected 4. Unusual
Answer: 2, 3, 5 Explanation: 2. Promoting maternal-infant attachment is a nursing intervention that fosters the process of becoming a mother. 3. Building awareness of and responsiveness to infant interactive capabilities is a nursing intervention that fosters the process of becoming a mother. 5. Preparing the woman for the maternal social role is a nursing intervention that fosters the process of becoming a mother.
19) Nursing interventions that foster the process of becoming a mother include which of the following? 1. Encouraging detachment from the nurse-patient relationship 2. Promoting maternal-infant attachment 3. Building awareness of and responsiveness to infant interactive capabilities 4. Instruct about promoting newborn independence 5. Preparing the woman for the maternal social role
Answer: 1, 2, 4 Explanation: 1. Providing a pacifier is an accepted method of soothing during the circumcision. 2. Stroking the head is an accepted method of soothing during the circumcision. 4. Talking to the infant is an accepted method of soothing during the circumcision.
2) The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following? Select all that apply. 1. Providing a pacifier 2. Stroking the head 3. Restraining both arms and legs 4. Talking to the infant 5. Giving the infant a sedative before the procedure
Answer: 2, 3, 4 Explanation: 2. Folding the diaper down to prevent coverage of the cord stump can prevent contamination of the area and promote drying. 3. Keeping the umbilical stump clean and dry can reduce the risk of infection. 4. It is the nurses responsibility to instruct parents in caring for the cord and observing for signs and symptoms of infection after discharge, such as foul smell, redness and greenish yellow drainage, localized heat and tenderness, or bright red bleeding or if the area remains unhealed 2 to 3 days after the cord has sloughed off.
20) Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord? Select all that apply. 1. Use triple-dye to cleanse the umbilical cord at home. 2. Fold the diaper down to prevent covering the cord stump. 3. Keep the umbilical stump clean and dry to avoid infection. 4. Observe for signs of infection such as foul smell, redness, and drainage. 5. Begin tub baths to help cleanse the cord stump at home.
Answer: 2, 3, 4 Explanation: 2. Immobility increases the risk of abdominal distention and discomfort. Leg exercises serve to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 3. Abdominal tightening serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 4. Early ambulation prevents abdominal distention that can occur with excess accumulation of gas in the intestines.
21) The nurse is caring for a client who delivered by cesarean birth. The client received a general anesthetic. To prevent or minimize abdominal distention, which of the following would the nurse encourage? Select all that apply. 1. Increased intake of cold beverages 2. Leg exercises every 2 hours 3. Abdominal tightening 4. Ambulation 5. Using a straw when drinking fluids
Answer: 3 Explanation: 3. If bleeding does occur, apply light pressure with a sterile gauze pad to stop the bleeding within a short time. If this is not effective, contact the physician immediately or take the newborn to the healthcare provider.
21) The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? 1. Wrap the diaper tightly. 2. Clean with warm water with each diaper change. 3. Apply gentle pressure to the site with gauze. 4. Apply a new petroleum ointment gauze dressing.
Answer: 1 Explanation: 1. Assessment findings consistent with endometritis are foul-smelling lochia, fever, uterine tenderness on palpation, lower abdominal pain, tachycardia, and chills.
21) The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following? 1. Purulent, foul-smelling lochia 2. Decreased blood pressure 3. Flank pain 4. Breast is hot and swollen
Answer: 2 Explanation: 2. Parent should be instructed to allow only people with proper birthing unit identification to remove the baby from the room. If parents do not know the staff person, they should call the nurse for assistance.
22) To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? 1. Keep the baby in the room at all times. 2. Check the identification of all personnel who transport the newborn. 3. Place a No Visitors sign on the door. 4. Keep the baby in the nursery at all times.
Answer: 3 Explanation: 3. Swaddling or bundling the baby increases a sense of security and is a quieting activity.
23) The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? 1. Hold the newborn in an upright position. 2. Massage the hands and feet. 3. Swaddle the newborn in a blanket. 4. Make eye contact while talking to the newborn.
Answer: 4 Explanation: 4. Newborn screening tests include hearing screening tests.
24) Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? 1. Preeclampsia screening 2. Congenital kidney disease screening 3. Visual screening 4. Hearing screening
Answer: 2 Explanation: 2. Breastfeeding should be initiated within the first hour of life unless medically contraindicated.
25) Placing the baby at mothers breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? 1. 6 to 12 hours after birth 2. Within 1 hour of birth 3. 24 hours after birth 4. 48 hours after birth
Answer: 1 Explanation: 1. Small, not large, amounts of uric acid crystals are normal in the first days of life.
26) The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? 1. Large amounts of uric acid crystals in the first days of life 2. At least 6 to 10 wet diapers a day after the first few days of life 3. 1 to 2 stools a day for formula-fed baby 4. Urine that is straw to amber color without foul smell
Answer: 1, 3, 4, 5 Explanation: 1. Parents should call their healthcare provider due to a continual rise in temperature. 3. Parents should call their healthcare provider in the absence of breathing longer than 20 seconds. 4. Parents should call their healthcare provider if the newborn exhibits lethargy and listlessness. 5. Parents should call their healthcare provider if the newborn has refused of two feedings in a row.
27) The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Select all that apply. 1. Continual rise in temperature 2. Decreased frequency of stools 3. Absence of breathing longer than 20 seconds 4. Lethargy 5. Refusal of two feedings in a row
Answer: 1 Explanation: 1. This client is at risk for urinary retention and bladder over distention. Over distention occurs postpartum when the woman is unable to empty her bladder, usually because of trauma or the effects of anesthesia. After the effects of anesthesia have worn off, if the woman cannot void, postpartum urinary retention is highly indicative of a urinary tract infection (UTI). Assisting the client to the bathroom is the most likely intervention that will prevent urinary retention.
28) The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client? 1. Assist the client to the bathroom in 2 hours to void. 2. Place a Foley catheter now. 3. Apply warm packs to the perineum three times a day. 4. Allow the client to rest for the next 8 hours.
Answer: 3 Explanation: 3. Foreskin will retract normally over time and may take 3 to 5 years.
29) New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? 1. The foreskin will be retractable at 2 months. 2. Retract the foreskin and clean thoroughly. 3. Avoid retracting the foreskin. 4. Use soap and Betadine to cleanse the penis daily.
Answer: 1, 2, 5 Explanation: 1. Diabetes mellitus is a risk factor for thromboembolic disease. 2. Varicose veins are a risk factor for thromboembolic disease. 5. Malignancy is a risk factor for thromboembolic disease.
29) Risk factors associated with increased risk of thromboembolic disease include which of the following? Select all that apply. 1. Diabetes mellitus 2. Varicose veins 3. Hypertension 4. Adolescent pregnancy 5. Malignancy
Answer: 2, 4, 5 Explanation: 2. The nurse can support the mother by encouraging her to share her feelings, by listening actively, and by being present for her. 4. The mother who decides to relinquish her baby needs emotional support and validation of her loss. The nurse should demonstrate empathy, concern, and compassion. 5. The nurse needs to acknowledge the significance of the birth mothers experience. The nurse should acknowledge the womans loss and support her decision.
29) What possible approaches should the nurse use to provide sensitive, holistic nursing care for the mother who is relinquishing her newborn? Select all that apply. 1. Allow the mother minimal control over the infant. 2. Use active listening strategies to determine the clients needs. 3. Provide only physical care in the early postpartum period. 4. Demonstrate empathy, concern, and compassion. 5. Provide nonjudgmental support and personalized care.
Answer: 1, 2, 4, 5 Explanation: 1. Palpating the fundus when the woman has a full bladder may give false information about the progress of involution. Ask the woman to void before assessment. 2. The nurse should provide an explanation of the purposes of regular assessment to the woman. 4. The woman should be relaxed before starting, and procedures should be performed as gently as possible, to avoid unnecessary discomfort. 5. Gloves should be worn before starting the assessment.
29) When preparing for and performing an assessment of the postpartum client, which of the following would the nurse do? Select all that apply. 1. Ask the client to void before assessing the uterus. 2. Inform the client of the need for regular assessments. 3. Defer client teaching to another time. 4. Perform the procedures as gently as possible. 5. Take precautions to prevent exposure to body fluids.
Answer: 4 Explanation: 4. A breastfeeding mother on antibiotics should check her babys mouth for signs of thrush, which should be reported to the physician.
30) A postpartum client with endometritis is being discharged home on antibiotic therapy. The new mother plans to breastfeed her baby. What should the nurses discharge instruction include? 1. The client can douche every other day. 2. Sexual intercourse can be resumed when the client feels up to it. 3. Light housework will provide needed exercise. 4. The babys mouth should be examined for thrush.
Answer: 3, 4, 5 Explanation: 3. The client should avoid overexertion. 4. The client should receive information and instruction on postpartum exercises. 5. The client should receive information on the need for adequate rest.
30) The nurse is planning discharge teaching for a postpartum woman. What information recommendations should the woman receive before being discharged? Select all that apply. 1. To abstain from sexual intercourse for 6 months 2. To avoid showers for 4 weeks 3. To avoid overexertion 4. To practice postpartum exercises 5. To obtain adequate rest
Answer: 1 Explanation: 1. The client should call the doctor if the incision becomes increasingly painful. After cesarean delivery, wound infection is most often associated with concurrent endometritis. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. Some women have cellulitis without actual purulent drainage.
31) The client delivered by cesarean birth 3 days ago and is being discharged. Which statement should the nurse include in the discharge teaching? 1. If your incision becomes increasingly painful, call the doctor. 2. It is normal for the incision to ooze greenish discharge in a few days. 3. Increasing redness around the incision is a part of the healing process. 4. A fever is to be expected because you had a surgical delivery.
Answer: 4 Explanation: 4. One-to-one teaching while the nurse is in the mothers room is shown to be the most effective educational model. Individual instruction is helpful to answer specific questions.
31) The nurse is analyzing various teaching strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? 1. Select videos on various topics of newborn care. 2. Organize a class that includes first-time mothers only. 3. Have mothers return in 1 week, when they feel more rested. 4. Schedule time for one-to-one teaching in the mothers room.
Answer: 4 Explanation: 4. Voiding only 2 or 3 times per day is not sufficient to prevent recurrence of a urinary tract infection (UTI). The woman needs to empty her bladder whenever she feels the urge to void at least every 2 to 4 hours while awake.
32) The client delivered her second child yesterday, and is preparing to be discharged. She expresses concern to the nurse because she developed an upper urinary tract infection (UTI) after the birth of her first child. Which statement indicates that the client needs additional teaching about this issue? 1. If I start to have burning with urination, I need to call the doctor. 2. Drinking 8 glasses of water each day will help prevent another UTI. 3. I will remember to wipe from front to back after I move my bowels. 4. Voiding 2 or 3 times per day will help prevent a recurrence.
Answer: 4 Explanation: 4. Another situation that can facilitate attachment is the interactive bath. While bathing their newborn for the first time, parents attend closely to their babys behavior and the nurse can observe and point out behaviors.
32) The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. I should avoid looking directly into the baby's eyes to prevent frightening the baby. 2. My baby will be very sleepy immediately after birth and should go to the nursery. 3. Newborns cannot focus their eyes, so it doesn't matter how I hold my new baby. 4. Giving the baby his first bath can really give me a chance to get to know him.
Answer: 4 Explanation: 4. The nurse must be sensitive to the cultural beliefs and values of the family and be aware of cultural variations in newborn care.
33) The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn? 1. You appear to be Muslim. Do you want your son circumcised? 2. Let me explain newborn care here in the United States. 3. Your baby is a United States citizen. You must be very happy about that. 4. Could you explain your preferences regarding childrearing?
Answer: 3 Explanation: 3. Postpartum depression has a high recurrence rate. Women with a history of postpartum psychosis or depression or other risk factors may benefit from a referral to a mental health professional for counseling during pregnancy or postpartum.
33) The postpartum client who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this client? 1. One visit from a homecare nurse, to take place in 2 days 2. Two visits from a public health nurse over the next month 3. An appointment with a mental health counselor 4. Follow-up with the obstetrician in 6 weeks
Answer: 1 Explanation: 1. Early discharge may be advantageous if mother and baby are doing well, help is available for the mother at home, and the family and physician/CNM agree that both clients are healthy and ready for discharge.
34) The nurse is assessing clients after delivery. For which client is early discharge at 24 hours after delivery appropriate? 1. Woman and baby who have had two successful breastfeedings 2. Woman who is bottle-feeding her infant and has not voided since delivery 3. Twins delivered at 35 weeks, bottle-feeding 4. Cesarean birth performed for fetal distress
Answer: 4 Explanation: 4. This response is best because bathing the newborn offers an excellent opportunity for teaching and welcoming parent involvement in the care of their baby.
34) The nurse is working with an adolescent parent. The adolescent tells the nurse, I'm really scared that I wont take care of my baby correctly. My mother says Ill probably hurt the baby because I'm too young to be a mother. What is the best response by the nurse? 1. You are very young, and parenting will be a challenge for you. 2. Your mother was probably right. Be very careful with your baby. 3. Mothers have instincts that kick in when they get their babies home. 4. We can give the baby's bath together. Ill help you learn how to do it.
Answer: 1, 2, 3, 5 Explanation: 1. Home visits, especially for early discharge families, are invaluable in fostering positive adjustments for the new family. 2. Telephone follow-up at 2 to 3 weeks postpartum to ask whether the mother is experiencing difficulties is also helpful. 3. Support groups in which child care is available can be an invaluable community service for the postpartum client. 5. Social support teaching guides are available to assist in helping postpartum women explore their needs for postpartum support.
34) Which interventions can the nurse utilize to provide continuity of care for the postpartal client who experienced a complication and is now ready to return home? Select all that apply. 1. Encourage the client to take advantage of home visits. 2. Make telephone calls as a follow-up to check on the client and newborn. 3. Provide information about postpartal support groups. 4. Refer to mental health professionals to help screen the client for any mental health problems as a result of the complications experienced in the hospital. 5. Supply information about postpartum expectations designed to meet the specific needs of a variety of families.
Answer: 1, 5 Explanation: 1. The newborn should be placed on his or her back (supine) for sleeping. 5. During the first few days of life, the newborn has increased mucus, and gentle suctioning with a bulb syringe may be indicated.
35) A mother and her newborn are being discharged 2 days after delivery. The general discharge instructions provided by the nurse include which of the following? Select all that apply. 1. Always place the infant in a supine position in the crib. 2. Support the infants head when carrying for the first week or two. 3. Do not allow the baby to fall asleep in someone's arms. 4. Cover the cord stump with a bandage. 5. Use a bulb syringe to suction mucus from the infants nostrils as necessary.
Answer: 3 Explanation: 3. In a progression of touching activities, the mother proceeds from fingertip exploration of the newborns extremities toward palmar contact with larger body areas and finally to enfolding the infant with the whole hand and arms. If the client continues to touch with only her fingertips, she might not be developing adequate early attachment.
35) A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn? 1. The client who is discussing how the baby looks like her father 2. The client who is singing softly to her baby 3. The client who continues to touch her baby with only her fingertips 4. The client who picks her baby up when the baby cries
Answer: 1, 3, 5 Explanation: 1. A clinical feature of PTSD is difficulty thinking. 3. A clinical feature of PTSD is intrusive thoughts and flashbacks to the threatening event. 5. A clinical feature of PTSD is irritability.
35) Clinical features of posttraumatic stress disorder (PTSD) include which of the following? 1. Difficulty sleeping 2. Acute awareness 3. Flashbacks 4. The need to be constantly around others 5. Irritability
Answer: 4 Explanation: 4. Rest, seclusion, and dietary restraint practices in many traditional non-Western cultures (South Asian groups) are designed to assist the woman and her baby during postpartum vulnerable periods.
36) The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior? 1. The client is not attaching to her infant appropriately. 2. The client is not going to be a good mother, and the baby is at risk. 3. The client has no mother present to role-model behaviors. 4. The client is exhibiting normal behavior for her culture.
Answer: 4 Explanation: 4. Oozing of greenish yellow material, or reddened areas around the cord is not an expected finding. This family should be seen first because the child is experiencing a complication.
36) The nurse is planning home visits to the homes of new parents and their newborns. Which client should the nurse see first? 1. 3-day-old male who received hepatitis B vaccine prior to discharge 2. 4-day-old female whose parents are both hearing-impaired 3. 5-day-old male with light, sticky, yellow drainage on the circumcision site 4. 6-day-old female with greenish discharge from the umbilical cord site
Answer: 4 Explanation: 4. Newborns must go home from the birthing unit in a car seat adapted to fit newborns.
37) The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? 1. The baby should be in the back seat. 2. Newborns must be in rear-facing car seats. 3. We need instruction on how to use the car seat before installing it. 4. We can bring the baby home from the hospital without a car seat as it is only a short drive home.
Answer: 4 Explanation: 4. A minimum of 6 to 10 wet diapers per day indicates adequate fluid intake.
38) The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? 1. Call your pediatrician if the babys temperature is below 98.6F axillary. 2. Your babys stools will change to a greenish color when your milk comes in. 3. You can wipe away any eye drainage that might form. 4. Your infant should wet a diaper at least 6 times per day.
Answer: 1, 2, 5 Explanation: 1. The nurse can be an excellent role model for families. Teaching by example is a very effective way to teach infant care. 2. One-to-one teaching while the nurse is in the clients room is shown to be the most effective educational model. 5. One-to-one teaching while the nurse is in the clients room is the most effective educational model.
39) Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit? Select all that apply. 1. Teach by example and role modeling when caring for the newborn in the clients room. 2. Teach at every opportunity, even during the night shift, if the occasion arises. 3. Teach using newborn care videos and group classes. 4. Teach using the 24-hour educational television channels in the clients room. 5. Teach using one-to-one instruction while in the clients room.
Answer: 1 Explanation: 1. Uterine atony (relaxation of the uterus) is the leading cause of early postpartum hemorrhage, accounting for over 50% of postpartum hemorrhage cases.
4) The client has experienced a postpartum hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the clients partner asks what would cause a hemorrhage. How should the nurse respond? 1. Sometimes the uterus relaxes and excessive bleeding occurs. 2. The blood collected in the vagina and poured out when your partner stood up. 3. Bottle-feeding prevents the uterus from getting enough stimulation to contract. 4. The placenta had embedded in the uterine tissue abnormally.
Answer: 1, 3, 4 Explanation: 1. The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing vital signs (body temperature, heart rate, respiratory rate). 3. The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing airway clearance. 4. The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing ability to feed.
4) The nurse initiates newborn admission procedures and evaluates the newborns need to remain under observation by assessing which of the following? Select all that apply. 1. Respiratory rate 2. Skin texture 3. Airway clearance 4. Ability to feed 5. Head weight
Answer: 1, 3, 4, 5 Explanation: 1. More than one episode of forceful vomiting or frequent vomiting over a 6-hour period should be reported to the healthcare provider. 3. Cyanosis (bluish discoloration of skin) with or without a feeding is a cause for concern, and should be reported to the healthcare provider immediately. 4. Refusal of two feedings in a row should be reported to the healthcare provider. 5. The infant should not have eye drainage after discharge and this condition should be reported to the healthcare provider.
40) The nurse is providing discharge teaching to the parents of a newborn. The nurse should instruct the parents to notify the healthcare provider in case of which of the following? Select all that apply. 1. More than one episode of forceful vomiting. 2. More than 6 to 10 wet diapers per day. 3. A bluish discoloration of the skin with or without a feeding. 4. Refusal of two feedings in a row. 5. Development of eye drainage.
Answer: 2, 3, 4 Explanation: 2. Infectious disease screening results help to determine if the infant is also at risk of obtaining any infectious diseases. 3. Gestational diabetes is a risk factor for the newborn. 4. Prolonged rupture of the membranes is a possible risk factor for the infant.
5) Prior to conducting the initial assessment of a newborn, the nurse reviews the mothers prenatal record and the delivery record to obtain information concerning possible risk factors for the infant and to anticipate the impact of these factors on the infants ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment? Select all that apply. 1. Drug or alcohol use by the father 2. Infectious disease screening results 3. Maternal history of gestational diabetes 4. Prolonged rupture of the membranes 5. Maternal use of prenatal vitamins
Answer: 1, 4, 5 Explanation: 1. A boggy fundus indicates that the uterus is not contracted and will continue to bleed. 4. Shiny or bulging skin could indicate the presence of a hematoma. 5. The uterine cavity can distend with up to 1000 mL or more of blood causing the fundus to rise.
5) The nurse is assessing a client who has been diagnosed with an early postpartum hemorrhage. Which findings would the nurse expect? Select all that apply. 1. A boggy fundus that does not respond to massage 2. Small clots and a moderate amount of lochia rubra on the pad 3. Decreased pulse and increased blood pressure 4. Hematoma formation or bulging/shiny skin in the perineal area 5. Rise in the level of the fundus of the uterus
Answer: 1, 3, 4, 5 Explanation: 1. 0.5 to 1 mg is the correct dosage for vitamin K. 3. 25-gauge, 5/8-inch needle is the right size needle to use. 4. Vitamin K must be kept away from light. 5. A prophylactic injection of vitamin K1 is given to prevent hemorrhage, which can occur because of low prothrombin levels in the first few days of life.
6) The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Select all that apply. 1. Administer a dose of 0.5 to 1 mg within 1 hour of birth. 2. Administer the injection subcutaneously. 3. Use a 25-gauge, 5/8-inch needle for the injection. 4. Protect the medication bottle from light. 5. Give vitamin K prior to a circumcision procedure.
Answer: 2 Explanation: 2. The nurse rechecks the temperature after the bath and, if it is stable, dresses the newborn in a shirt, diaper, and cap; wraps the baby; and places the baby in an open crib at room temperature. If the babys axillary temperature is below 36.5C (97.7F), the nurse returns the baby to the radiant warmer. The rewarming process should be gradual to prevent the possibility of hyperthermia.
7) The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? 1. Heart rate 120 2. Temperature 96.8F 3. Respiratory rate 50 4. Temperature 99.6F
Answer: 1 Explanation: 1. Eye prophylaxis medication instillation may be delayed up to 1 hour after birth to allow eye contact during parent-newborn bonding.
8) In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? 1. Eye prophylaxis medication 2. Drying the newborn 3. Vital signs 4. Vitamin K injection
Answer: 1 Explanation: 1. After administration, the nurse massages the eyelid gently to distribute the ointment.
9) Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following? 1. Massaging eyelids gently following application 2. Irrigating eyes after instillation 3. Using a syringe to apply ointment 4. Instillation is in the upper conjunctival surface of each eye
Answer: 3 Explanation: 3. Uterine atony is a cause of postpartal hemorrhage. A contributing factor to uterine atony is oxytocin augmentation of labor.
1) The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage? 1. The client who was overdue and delivered vaginally 2. The client who delivered by scheduled cesarean delivery 3. The client who had oxytocin augmentation of labor 4. The client who delivered vaginally at 36 weeks
Answer: 1 Explanation: 1. The amount, consistency, color, and odor of the lochia are monitored on an ongoing basis. Increased bleeding is most often related to uterine atony and responds to fundal massage, expression of any clots, and emptying the bladder.
1) The nurse assesses the postpartum client to have moderate lochia rubra with clots. Which nursing intervention would be appropriate? 1. Assess fundus and bladder status. 2. Catheterize the client. 3. Administer Methergine IM per order. 4. Contact the physician immediately.
Answer: 1, 2, 4, 5 Explanation: 1. Redness is a classic sign of a perineal wound infection. 2. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 4. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 5. Purulent drainage is a classic signs of a perineal wound infection.
12) Which findings would indicate the presence of a perineal wound infection? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Redness 2. Tender at the margins 3. Vaginal bleeding 4. Hardened tissue 5. Purulent drainage
Answer: 2, 3, 5 Explanation: 2. Anger would be a symptom of postpartum blues. 3. Mood swings would be a symptom of postpartum blues. 5. Weepiness and crying would be a symptom of postpartum blues.
18) Which of the following symptoms would be an indication of postpartum blues? Select all that apply. 1. Overeating 2. Anger 3. Mood swings 4. Constant sleepiness 5. Crying
Answer: 2 Explanation: 2. Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is not firm, gentle fundal massage is performed until the uterus contracts.
2) The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What would be the first action of the nurse? 1. Assist the client to empty her bladder 2. Help the client back to bed to check the fundus 3. Assess her blood pressure and pulse 4. Begin an IV of lactated Ringers solution
Answer: 3 Explanation: 3. This is an open-ended question about an important physiologic issue. A discussion that includes both partners can facilitate an open dialog between them and can provide an opportunity for questions and answers.
2) The nurse is providing education to the new family. Which question by the nurse is best? 1. Do you know how to give the baby a bath? 2. You have diapers and supplies at home, right? 3. How have your breastfeedings been going? 4. How much formal education do you have?
Answer: 2, 3 Explanation: 2. Frequency is characteristic of acute cystitis. 3. Suprapubic pain is characteristic of acute cystitis.
27) The postpartum client is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this client? Select all that apply. 1. High fever 2. Frequency 3. Suprapubic pain 4. Chills 5. Nausea and vomiting
Answer: 1, 3 Explanation: 1. Methergine is commonly used orally for postpartum hemorrhage. 3. Misoprostol is commonly used rectally for postpartum hemorrhage.
3) A client is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? Select all that apply. 1. Methergine 2. Coumadin 3. Misoprostol 4. Serotonin reuptake inhibitors (SSRIs) 5. Nonsteroidal anti-inflammatory drugs
Answer: 1 Explanation: 1. A common cause of neonatal distress is early-onset group B streptococcal (GBS) disease. Infected mothers transmit GBS infection to their infants during labor and birth. All infants of mothers identified as at risk should be assessed and observed for signs and symptoms of sepsis.
3) The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? 1. The infants mother has group B streptococcal (GBS) disease. 2. The infants mother had an IV of lactated Ringers solution. 3. The infants mother had a labor that lasted 12 hours. 4. The infants mother had a cesarean birth with her last child.
Answer: 1 Explanation: 1. Parents should check cord each day for any odor, oozing of greenish yellow material, or reddened areas around the cord. They should report to healthcare provider any signs of infection.
30) A postpartum client calls the nursery to report that her newborns umbilical cord stump is draining, and has a foul odor. What is the nurses best response? 1. Take your newborn to the pediatrician. 2. Cover the cord stump with gauze. 3. Apply Betadine around the cord stump. 4. This is normal during healing.
Answer: 4 Explanation: 4. Helping the mother to identify her babys behavior cues facilitates the acquaintance phase of maternal-infant attachment.
33) The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important? 1. Describe the likely reaction of siblings to the new baby. 2. Discuss adaptation to grandparenthood by her parents. 3. Determine whether father-infant attachment is taking place. 4. Assist the mother in identifying the babys behavior cues.
Answer: 3 Explanation: 3. The nurse would massage the uterine fundus until it is firm by keeping one hand in position and stabilizing the lower portion of the uterus. With one hand used to massage the fundus, the nurse would put steady pressure on the top of the now-firm fundus and to see if she was able to express any clots.
1) The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do? 1. Document the findings. 2. Catheterize the client. 3. Massage the uterine fundus until it is firm. 4. Call the physician immediately.
Answer: 1 Explanation: 1. A sitz bath or tub bath promotes healing and provides relief from perineal discomfort during the initial weeks following birth.
33) The nurse is performing discharge teaching for a newly delivered first-time mother and her infant on the 2nd postpartum day. Which statement by the mother indicates that teaching has been successful? 1. Taking baths will help my perineum feel less sore each day. 2. If I develop heavy bleeding, I should take my temperature. 3. My bowel movements should resume in a week. 4. I will go back to the doctor in 4 days for my RhoGAM shot.
Answer: 2 Explanation: 2. Ideally, initial skin-to-skin contact is immediate. The benefits of this practice are supported by a preponderance of evidence.
13) The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction? 1. The en face position promotes bonding and attachment. 2. Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed. 3. In reciprocity, the interaction of mother and infant is mutually satisfying and synchronous. 4. The needs of the mother and of her infant are balanced during the phase of mutual regulation.
Answer: 4 Explanation: 4. Couplet care, which is care of both the mother and her baby, is an important part of the family-centered care approach, in which the infant remains at the mothers bedside and both are cared for by the same nurse.
14) The hospital is developing a new maternity unit. What aspects should be included in the planning of the new unit to best promote family wellness? 1. Normal newborn nursery centrally located to all client rooms 2. A kitchen with a refrigerator stocked with juice and sandwiches 3. Small, cozy rooms with a client bed and rocking chair 4. A nursing care model based on providing couplet care
Answer: 2, 3 Explanation: 2. In Muslim cultures, emphasis on childrearing and infant care activities is on the mother and female relatives. 3. Women of the Islamic faith may have specific modesty requirements; the woman must be completely covered, with only her feet and hands exposed.
14) The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client? Select all that apply. 1. To be sure she gets a kosher diet. 2. Expect that most visitors will be women. 3. Uncover only the necessary skin when assessing. 4. The father will take an active role in infant care. 5. She will prefer a male physician.
Answer: 1 Explanation: 1. Rest, seclusion, and dietary restraint practices in many traditional non-Western cultures (South Asian groups) are designed to assist the woman and her baby during postpartum vulnerable periods.
15) The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following? 1. Help the new mother by allowing her to focus on resting and caring for the baby. 2. Teach her son-in-law the right way to be a father because this is his first child. 3. Make sure that her daughter does not become abusive towards the infant. 4. Pass on the cultural values and beliefs to the newborn grandchild.
Answer: 2 Explanation: 2. Hearing voices is an indication the client is experiencing postpartum psychosis, and is the highest priority because the voices might tell her to harm her baby.
15) The nurse is calling clients at 4 weeks postpartum. Which of the following clients should be seen immediately? 1. The client who describes feeling sad all the time 2. The client who reports hearing voices talking about the baby 3. The client who states she has no appetite and wants to sleep all day 4. The client who says she needs a refill on her sertraline (Zoloft) next week
Answer: 2 Explanation: 2. In a mother-baby unit, the newborns crib is placed near the mothers bed, where she can see her baby easily; this is conducive to an on-demand feeding schedule for both breastfeeding and formula-feeding infants.
16) A new grandmother comments that when her children were born, they stayed in the nursery. The grandmother asks the nurse why her daughters baby stays mostly in the room instead of the nursery. How should the nurse respond? 1. Babies like to be with their mothers more than they like to be in the nursery. 2. Contact between parents and babies increases attachment. 3. Budget cuts have decreased the number of nurses in the nursery. 4. Why do you ask? Do you have concerns about your daughters parenting?
Answer: 1 Explanation: 1. Because of the traumatic nature of the birth and the clients symptoms, this condition is most likely post-traumatic stress disorder (PTSD). At particular risk for PTSD are women who have histories of prior trauma and/or prior psychiatric histories and women who undergo emergency cesarean sections.
16) The home health nurse is visiting a new mother whose baby was delivered by emergency cesarean after a car accident. The mother seems dazed, irritable, and unaware of her surroundings. She tells the nurse she has had trouble sleeping. What would the nurse suspect that the mother has? 1. Post-traumatic stress disorder 2. Postpartum blues 3. Postpartum psychosis 4. Disenfranchised grief
Answer: 1, 4, 5 Explanation: 1. A warm water bottle placed against the low abdomen may reduce the discomfort of afterpains. 4. The breastfeeding mother may find it helpful to take a mild analgesic agent approximately 1 hour before feeding her infant. 5. An analgesic agent such as ibuprofen is also helpful at bedtime if the afterpains interfere with the mothers rest.
2) The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain? Select all that apply. 1. Offer a warm water bottle for her abdomen. 2. Call the physician to report this finding. 3. Inform her that this is not normal, and she will need an oxytocic agent. 4. Administer a mild analgesic to help with breastfeeding. 5. Administer a mild analgesic at bedtime to ensure rest.
Answer: 2 Explanation: 2. The client may talk about her labor and birth experience. The nurse should provide opportunities to discuss the birth experience in a nonjudgmental atmosphere if the woman desires to do so.
10) Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take? 1. Answer questions quickly and try to divert her attention to other subjects. 2. Review the documentation of the birth experience and discuss it with her. 3. Contact the physician to warn him the client might want to file a lawsuit, based on her preoccupation with the birth experience. 4. Submit a referral to Social Services because of possible obsessive behavior.
Answer: 3 Explanation: 3. Treatment for superficial thrombophlebitis involves application of local heat, elevation of the affected limb, and analgesic agents.
10) Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis? 1. Urge ambulation 2. Apply ice to the leg 3. Elevate the affected limb 4. Massage her calf
Answer: 2 Explanation: 2. Increasing pulse, widening pulse pressure would be considered a clinical sign of hemorrhage.
11) Which of the following would be considered a clinical sign of hemorrhage? 1. Increased blood pressure 2. Increasing pulse 3. Increased urinary output 4. Hunger
Answer: 1, 2, 4 Explanation: 1. It is important for nurses to recognize that they are approaching their patients care from their own perspective and that, to individualize care for each mother, they need to assess the womans preferences, her level of acculturation and assimilation to Western culture, her linguistic abilities, and her educational level. 2. It is important for nurses to recognize that they are approaching their patients care from their own perspective and that, to individualize care for each mother, they need to assess the womans preferences, her level of acculturation and assimilation to Western culture, her linguistic abilities, and her educational level. 4. The nurse should have the mother exercise her choices when possible and support those choices, with the help of cultural awareness and a sound knowledge base.
16) Which strategies would the nurse utilize to promote culturally competent care for the postpartum client? Select all that apply. 1. Examine ones own cultural beliefs, biases, stereotypes, and prejudices. 2. Respect the values and beliefs of others. 3. Limit the alternative food choices offered clients to minimize conflicts. 4. Incorporate the familys cultural practices into the care. 5. Evaluate whether the familys cultural practices fit into Western norms.
Answer: 4 Explanation: 4. The continuous seepage of blood is more consistent with cervical or vaginal lacerations. Lacerations should be suspected if the uterus is firm and of expected size and if no clots can be expressed. This finding would indicate a follow-up.
23) During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up? 1. Firm fundus 2. Fundus at the umbilical level 3. Moderate lochia rubra 4. Steady trickle of blood
Answer: 3 Explanation: 3. The most common clinical findings of a pulmonary embolism include dyspnea, pleuritic chest pain, cough with or without hemoptysis, cyanosis, tachypnea and tachycardia, panic, syncope, or sudden hypotension and require immediate intervention.
23) The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? 1. The client reports she had this condition after her last pregnancy. 2. The client develops pain and swelling in her left lower leg. 3. The client appears anxious, and describes pressure in her chest. 4. The client becomes upset that she cannot go home yet.
Answer: 2, 3, 4 Explanation: 2. Immobility after delivery increases the risk of pulmonary infection. 3. Immobility after delivery increases the risk of deep vein thrombosis. 4. Immobility after delivery increases the risk of pulmonary embolism.
23) When caring for a new mother after cesarean birth, what complications would the nurse anticipate? Select all that apply. 1. Back pain 2. Pulmonary infection 3. Deep vein thrombosis 4. Pulmonary embolism 5. Perineal edema
Answer: 1, 2, 3 Explanation: 1. Mastitis is characterized by shooting pain between feedings, often radiating to the chest wall. 2. Mastitis is characterized by late-onset nipple pain. 3. The skin of the affected breast becomes pink, flaking, and pruritic.
24) A nurse suspects that a postpartum client has mastitis. Which data support this assessment? Select all that apply. 1. Shooting pain between breastfeedings 2. Late onset of nipple pain 3. Pink, flaking, pruritic skin of the affected nipple 4. Nipple soreness when the infant latches on 5. Pain radiating to the underarm area from the breast
Answer: 3 Explanation: 3. Some adolescents may not have a working knowledge of their own anatomy and physiology or the related terminology, and they may require special assistance with postpartum hygiene and care.
24) The nurse is supervising a student nurse who is working with a 14-year-old client who delivered her first child yesterday. Which statement indicates that the nursing student understands the particular needs of an adolescent client? 1. This client will need less teaching, because she will have gotten the right information in school. 2. Because of her age, this client will require less frequent fundal checks to assess for postpartal hemorrhage. 3. Because of her age, this client will probably need extra teaching about the terminology for her anatomy. 4. This client will need to have her grandmother provide day care and help raise the baby.
Answer: 2 Explanation: 2. The use of sequential compression devices (SCDs) and early ambulation are essential to the prevention of deep vein thrombosis, especially if the client had a cesarean birth.
20) The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, Im wondering what will be different this time compared with my first birth, which was vaginal. What response is best? 1. Well take good care of you and your baby. Youll be home before you know it. 2. Youll be wearing a sequential compression device until you start walking. 3. You will have a lot of pain, but there are medications that we give when it gets really bad. 4. You wont be able to nurse until the baby is 12 hours old, because of your epidural.
Answer: 3 Explanation: 3. Postpartum depression can impair maternal-infant bonding and can cause developmental and cognitive delays in the child.
20) The postpartum client states that she doesnt understand why she cant enjoy being with her baby. What would the nurse be concerned about? 1. Postpartum psychosis 2. Postpartum infection 3. Postpartum depression 4. Postpartum blues
Answer: 3 Explanation: 3. The nurse will assess for postpartum hemorrhage. Overstretching of uterine muscles with conditions such as multiple gestation, polyhydramnios, or a very large baby may set the stage for slower uterine involution.
20) The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following? 1. Increased blood pressure 2. Hypoglycemia 3. Postpartum hemorrhage 4. Postpartum infection
Answer: 3 Explanation: 3. The patient should be offered premedication 30-45 minutes before assessing the fundus, especially if the patient has had a cesareansection.
21) The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse? 1. Asking the client to void and donning clean gloves 2. Listening to bowel sounds and then asking when her last bowel movement occurred 3. Offering the patient pre-medication 2 hours before the assessment 4. Completing the assessment and explaining the results to the client
Answer: 2 Explanation: 2. Women with cesarean births have special needs: increased need for rest and sleep; incisional care; self-care; and relief of pain and discomfort.
22) A multiparous client delivered her first child vaginally 2 years ago, and delivered an infant by cesarean yesterday due to breech presentation. Which statement would the nurse expect the client to make? 1. I cant believe how much more tired I was with the first baby. 2. Im having significantly more pain this time than with my last birth. 3. It is disappointing that I cant breastfeed because of the cesarean. 4. Getting in and out of bed feels more comfortable than last time.
Answer: 3 Explanation: 3. A newborn physical examination performed at the bedside gives the parent(s) immediate feedback about the newborns health and demonstrates methods of handling an infant. This action helps the client learn about her baby as an individual and facilitates maternal-infant attachment. This is the highest priority.
25) The nurse is caring for a 15-year-old client who gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent? 1. The clients mother is included in all discussions and demonstrations. 2. The father of the baby is encouraged to change a diaper and give a bottle. 3. The nurse explains the characteristics and cues of the baby when assessing him. 4. A discussion on contraceptive methods is the first topic of teaching.
Answer: 1 Explanation: 1. Cesarean birth is the single most significant risk of postpartum endometritis as well as prolonged premature rupture of the amniotic membranes (PPROM).
25) The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this clients chart? 1. Cesarean birth after extended labor with ruptured membranes. 2. Unassisted childbirth and afterbirth. 3. External fetal monitoring used throughout labor. 4. The client has history of pregnancy-induced hypertension.
Answer: 1, 2, 3, 4 Explanation: 1. It is helpful for the nurse to advise parents that they may experience feelings of uncertainty as they grow into the parental role and alter their family processes to accommodate the new family member. 2. Guidance is essential in assisting the family to cope with role changes and the realities of a new baby. 3. Guidance is essential in assisting the family to cope with potential complications such as infant colic and postpartum health issues. 4. It is important for the nurse to present information about changes that may affect sexual activity and to discuss the importance of contraception during the early postpartum period.
3) The postpartum nurse provides anticipatory guidance for the new mother as well as teaching on self-care and infant care before discharge. Which topics should be included? Select all that apply. 1. Role changes brought on by the addition to the family unit 2. The realities of having a new baby, and how it affects previous lifestyle 3. Potential complications such as infant colic and postpartum issues 4. Sexuality and contraception 5. Toilet-training and preschool options
Answer: 2, 4, 5 Explanation: 2. During the first several postpartum weeks, the new mother must adapt to altered lifestyles and family structure resulting from the addition of a new member. 4. During the first several postpartum weeks, the new mother must restore her physical condition. 5. During the first several postpartum weeks, the new mother must develop competence in caring for and meeting the needs of her infant.
32) During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following? Select all that apply. 1. Establish a therapeutic relationship with her physician 2. Adapt to altered lifestyles and family structure resulting from the addition of a new member 3. Restore her intellectual abilities 4. Restore physical condition 5. Develop competence in caring for and meeting the needs of her infant
Answer: 2, 4 Explanation: 2. A firm fundus that is midline indicates the normal progression of uterine involution. 4. During the early postpartum period, the soft tissue in and around the perineum may appear edematous with some bruising.
30) Which physical assessment findings would the nurse consider normal for the postpartum client following a vaginal delivery? Select all that apply. 1. Elevated blood pressure 2. Fundus firm and midline 3. Moderate amount of lochia serosa 4. Edema and bruising of perineum 5. Inflamed hemorrhoids
Answer: 3 Explanation: 3. Knowing how to contact their healthcare provider at all times is critical so that clients receive appropriate advice and care in case of a problem or emergency. Knowing what to watch for and when to call the healthcare provider also facilitates safety. These are the highest priorities.
31) The nurse is preparing a teaching brochure for Spanish-speaking postpartum clients. Which topics are critical for this population? 1. Baby baths and birth certificates 2. Hygiene practices 3. When and how to contact their healthcare provider 4. Pain-relief options in labor and after birth
Answer: 3 Explanation: 3. Diastasis recti abdominis can be improved with exercise and abdominal muscle tone can improve significantly best taught when the mother is receptive to instruction during the postpartum assessment.
31) The postpartum client is about to go home. The nurse includes which subject in the teaching plan? 1. Replacement of fluids 2. Striae 3. Diastasis of the recti muscles 4. REEDA scale
Answer: 4 Explanation: 4. Effective parent learning requires precise timing of teaching, as well as choice of a teaching method that is effective for the family, such as DVDs and return demonstration. Content on self-care, infant care, and anticipatory guidance is important.
32) To actively involve the postpartal client during discharge teaching, the postpartum nurse applies which learning principle? 1. Reprints of magazine articles 2. Classroom lectures 3. Audiotapes 4. Interactive nurse-patient relationships
Answer: 1, 2, 3, 5 Explanation: 1. Postpartum nurses need to be aware of the long-term adjustments and stresses that the childbearing family faces as its members adjust to new and different roles. 2. Postpartum nurses need to be aware of the long-term adjustments and stresses that the childbearing family faces as its members adjust to new and different roles. 3. New mother support groups are helpful for women who lack a social support system. 5. Postpartum doulas are professionals trained to help the new mother after the birth of the baby.
34) At her 6-week postpartum checkup, a new mother voices concerns to the nurse. She states that she is finding it hard to have time alone to even talk on the phone without interruption. Her family lives in another state, and she has contact with them only by phone. She is still having difficulty getting enough sleep and worries that she will not be a good mother. Appropriate nursing interventions would include providing which of the following? Select all that apply. 1. Anticipatory guidance about the realities of being a parent. 2. Parenting literature and reference manuals. 3. Phone numbers and locations of local parenting groups. 4. Referral for specialized interventions related to postpartum blues. 5. Phone numbers and names of postpartum doulas.
Answer: 3 Explanation: 3. Physical fatigue often affects adjustments and functions of the new mother. The nurse can also provide information about the fatigue that a new mother experiences, strategies to promote rest and sleep at home, and the impact fatigue can have on a womans emotions and sense of control.
37) The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make? 1. I have a lot more time to myself than I thought I would have. 2. My confidence level in my parenting is higher than I anticipated. 3. I am constantly tired. I feel like I could sleep for a week. 4. My baby likes everyone, and never fusses when shes held by a stranger.
Answer: 1 Explanation: 1. A variety of drugs are used alone or in combination to provide relief of postpartum pain. An option would include nonsteroidal anti-inflammatory agents such as ibuprofen and ketorolac.
7) A variety of drugs are used either alone or in combination to provide relief of postpartum pain. Which of the following would be an option for pain relief? 1. Nonsteroidal anti-inflammatory agents 2. Proquad 3. Methergine 4. Intravenous oxytocin
Answer: 2 Explanation: 2. An initial weight loss of 10 to 12 lbs. occurs as a result of the birth of infant, placenta, and amniotic fluid.
7) The nurse expects an initial weight loss for the average postpartum client to be which of the following? 1. 5 to 8 pounds 2. 10 to 12 pounds 3. 12 to 15 pounds 4. 15 to 20 pounds
Answer: 2 Explanation: 2. The client must avoid pregnancy for at least 1 month after receiving the rubella vaccine.
5) A postpartum client has just received a rubella vaccination. The client demonstrates understanding of the teaching associated with administration of this vaccine when she states which of the following? 1. I will need another vaccination in 3 months. 2. I must avoid getting pregnant for 1 month. 3. This will prevent me from getting chickenpox. 4. This will protect my newborn from getting the measles.
Answer: 4 Explanation: 4. Obtaining an order for a stool softener is the correct intervention by the third day. In resisting or delaying the bowel movement, the woman may cause increased constipation and more pain when elimination finally occurs.
5) The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate? 1. Encourage the new mother, saying, It will happen soon. 2. Instruct the client to eat a low-fiber diet. 3. Decrease fluid intake. 4. Obtain an order for a stool softener.
Answer: 1, 3, 4, 5 Explanation: 1. Pain can be a discomfort in the first year postpartum. 3. Urinary incontinence can be a complication in the first year postpartum. 4. Changes in mental health status can be a complication in the first year postpartum. 5. Sleep deprivation can be a complication in the first year postpartum.
6) The incidence of complications and discomforts in the first year postpartum is common and women may experience which of the following? Select all that apply. 1. Pain 2. Excess energy 3. Urinary incontinence 4. Changes in mental health status 5. Sleep deprivation
Answer: 2 Explanation: 2. This client is the top priority. The fundus should not be positioned above the umbilicus after delivery. If the fundus is in the midline but higher than expected, it is usually associated with clots within the uterus.
6) The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first? 1. Woman who is 2nd day post-cesarean, moderate lochia serosa 2. Woman day of delivery, fundus firm 2 cm above umbilicus 3. Woman who had a cesarean section, 1st postpartum day, 4 cm diastasis recti abdominis 4. Woman who had a cesarean section, 1st postpartum day, hypoactive bowel sounds all quadrants
Answer: 1, 4 Explanation: 1. Weighing the perineal pads will indicate whether the client is bleeding more than anticipated. 4. The nurse reviews hemoglobin and hematocrit levels when available, and compares them to the admission baseline.
6) The nurse is caring for a postpartum client who is at risk for developing early postpartum hemorrhage. What interventions would be included in the plan of care to detect this complication? Select all that apply. 1. Weigh perineal pads if the client has a slow, steady, free flow of blood from the vagina. 2. Massage the uterus every 2 hours. 3. Maintain vascular access. 4. Obtain blood specimens for hemoglobin and hematocrit. 5. Encourage the client to void if the fundus is displaced upward or to one side.
