OB Exam #2 Study set
A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. "You will need to wait 3 months before resuming sexual intercourse." B. "You don't need to use contraception until you are 4 months postpartum." C. "As long as you breastfeed, you will experience an overproduction of vaginal lubrication." D. "A reduction in sexual interest could indicate postpartum depression."
"A reduction in sexual interest could indicate postpartum depression."
A nurse is caring for a client who is postpartum and non-lactating. The client reports breast pain. Which of the following statements should the nurse make? A. "Try taking a warm shower." B. "Be sure to wear a well-fitted supportive bra." C. "Expel breast milk using your hand." D. "Avoid laying your newborn on your chest until the pain subsides."
"Be sure to wear a well-fitted supportive bra."
A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? A. "Call me so I can check your baby's latch the next time you breastfeed." B. "You should reduce the frequency of breastfeeding." C. "Apply expressed breast milk to sore nipples and cover them with nursing pads and a bra." D. "You should apply warm packs to the breasts between nursing sessions."
"Call me so I can check your baby's latch the next time you breastfeed."
A nurse is providing teaching to a client who is 1 hour postpartum about using the perineal squeeze bottle. Which of the following instructions should the nurse include? A. "Fill the perineal bottle with warm water prior to use." B. "Squeeze the perineal bottle while standing up in the bathroom to cleanse the perineum." C. "Only use hald of the perineal bottle for cleansing." D. "Wipe the perineum with toilet paper from back to front after using the perineal bottle."
"Fill the perineal bottle with warm water prior to use."
A nurse is reinforcing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding? A. "I will need to use contraception for 3 months before considering pregnancy." B. "I need a second vaccination at my postpartum visit." C. "I was given the vaccine because my baby is O-positibe D. "I will be tested in 3 months to see if I have developed immunity."
"I need a second vaccination at my postpartum visit."
A nurse is reinforcing teaching about the rubella immunization with a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching? A. "I should not breastfeed for at least 3 days after receiving this immunization." B. "I will need a second rubella booster when I see my midwife at 6 weeks postpartum." C. "I should be careful to avoid becoming pregnant within the next month." D. "This vaccine will be given into my arm muscle."
"I should be careful to avoid becoming pregnant within the next month."
A nurse is reinforcing teaching with a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching? A. "I should feed my baby 8 to 12 times a day, based on feeding cues." B. "My baby should have 6 or 7 wet diapers during the first week." C. "I should switch my baby to the other breast after 15 min." D. "My nipple pain should go away after a few weeks of breastfeeding."
"I should feed my baby 8 to 12 times a day, based on feeding cues."
A nurse is reinforcing with teaching a postpartum client about how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A. "I should stop swaddling my baby once she is able to roll over by herself." B. "My baby's legs should be extended straight out when I swaddle her." C. "I should be able to slide just 1 finger between my baby's chest and the swaddled blanket." D. "After swaddling, I should place my baby on her side in her crib or bassinet."
"I should stop swaddling my baby once she is able to roll over by herself."
A nurse is caring for a client who is 6 hours postpartum following a dysfunctional labor. Which of the following statements by the client indicates a possible complication? A. "Suddenly, I seem to be urinating all the time." B. "I am really thirsty and hungry this morning." C. "I think I have changed my pad every 15 minutes." D. "Honestly, I'm so tired I don't want to hold the baby."
"I think I have changed my pad every 15 minutes."
A nurse is reinforcing teaching about mastitis with a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."
"I will avoid any of my family members who are ill."
A nurse is assisting the charge nurse with reviewing postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching? A. "I am glad I can have my morning coffee." B. "I should take folic acid to increase my milk supply." C. "I will continue adding 330 calories per day to my diet." D. "I will continue my calcium supplements because I don't like milk."
"I will continue my calcium supplements because I don't like milk."
A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I can store my pumped milk in the door of the refigerator." B. "I can use the microwave to thaw my frozen breast milk." C. "I will discard any unused breastmilk that is ieft in the bottle." D. "I can refreeze any breastmilk after it has been thawed."
"I will discard any unused breastmilk that is ieft in the bottle."
A nurse is reinforcing teaching about newborn safety with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will put bumper pads in the crib." B. "I will warm my baby's formula in the microwave on a low-setting." C. "I will place my baby on his stomach to sleep." D. "I will purchase a firm mattress for the crib."
"I will purchase a firm mattress for the crib."
A nurse is reinforcing teaching about newborn umbilical cord care with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will report any drainage from my baby's umbilical cord." B. "I will wash my baby's umbilical cord with soapy water." C. "I will expect my baby's umbilical cord to fall off in 2 to 3 days." D. "I will secure the diaper over my baby's umbilical cord."
"I will report any drainage from my baby's umbilical cord." *sign of infection
A nurse is reinforcing discharge teaching with a postpartum client regarding elimination. Which of the following statements should the nurse include in the teaching? A. "You should urinate at least twice daily." B. "Increase fluids to help prevent constipation." C. "Put your hand under running cold water if you experience hesitancy when trying to urinate." D. "You should use laxatives daily to keep your bowel movements regular."
"Increase fluids to help prevent constipation."
A nurse is reinforcing teaching with a group of clients about pregnancy prevention during the postpartum period. Which of the following statements should the nurse include? A. "Non-lactating clients can ovulate immediately after giving birth." B. "Non-lactating clients ovulate in their third month postpartum on average." C. "Lactating clients can ovulate as early as their first month postpartum." D. "Lactating clients ovulate in their sixth month postpartum on average."
"Lactating clients ovulate in their sixth month postpartum on average."
A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make? A. "Losing 2.2 pounds each month would be acceptable." B. "Losing 4.4 pounds each month would be acceptable." C. "Losing 5.5 pounds each month would be acceptable." D. "Losing 6.6 pounds each month would be acceptable."
"Losing 2.2 pounds each month would be acceptable."
A nurse is reinforcing postpartum teachings with a client who is non-lactating about breast discomfort. Which of the following interventions should the nurse discuss with the client? A. "Wear a loose-fitting bra to alleviate breast discomfort." B. "Place fresh cabbage leaves on your breasts." C. "Apply warm, moist compresses to your breasts." D. "Express small amount of milk from the breasts frequently."
"Place fresh cabbage leaves on your breasts."
A nurse on a postpartum unit is reinforcing teaching with a client about postpartum blues. Which of the following instructions should the nurse include? A. "Seek immediate assistance for feelings of fatigue." B. "Plan opportunities to get out of the house frequently." C. "You will experience intense fears and anxiety if you have postpartum blues." D. "Most parents feel angry when the baby cries."
"Plan opportunities to get out of the house frequently."
A nurse is caring for a client who is 48 hours postpartum. The client expresses distress about her older children's acceptance of the new baby. Which of the following statements should the nurse make? A. "It would be best if your children met the new baby at home in a familiar setting." B. "Present the older children with a small gift and say it is from the baby." C. "Make sure you are holding the baby when the older children come to visit." D. "Try not to split up the children so no one will feel left out."
"Present the older children with a small gift and say it is from the baby."
A nurse is reinforcing teaching with a postpartum client about the proper technique for performing Kegel exercises. Which of the following statements should the nurse make? A. "Pretend you are urinating and stop your uterine stream intermittently." B. "You should bear down as if you are passing gas during the exercises." C. "You should feel tightening in the buttocks during the exercises." D. "Each muscle contraction should be held for a minimum of 30 seconds."
"Pretend you are urinating and stop your uterine stream intermittently."
A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? A. "You will not get pregnant while you are breastfeeding, so you will not need any birth control." B. "A birth control pill that contains only estrogen is available for use while you are breastfeeding." C. "Condoms are the only method of contraception that is appropriate while you are breastfeeding." D. "Progestin-only pill or injection is available for use while you are breastfeeding."
"Progestin-only pill or injection is available for use while you are breastfeeding."
A nurse is assisting with the care of a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. "This could indicate a possible uterine infection." B. "The bleeding is minimal until I discontinue your IV medication." C. "You might have retained some fragments of your placenta." D. "You will require additional medication to increase your bleeding."
"The bleeding is minimal until I discontinue your IV medication."
A nurse is collecting data from a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. "Prolactin is increasing the blood supply to your uterus, and you are feeling the blood vessel engorgement." B. "You probably have a small blood clot in your uterus, which is causing to contract in order to expel it." C. "Your breasts are secreting a hormone that enters the bloodwstream and causes your abdominal muscles to contract." D. "The same hormone that is released in response to the baby's suckling, causing the milk to flow, also makes the uterus contract."
"The same hormone that is released in response to the baby's suckling, causing the milk to flow, also makes the uterus contract."
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make?A. "This is an attempt by your body to retain the fluid gained during pregnancy."B. "This is caused by an increase in your estrogen hormonal levels."C. "This is caused by the increased pressure on your veins in your lower legs."D. "This is a source of your fluid loss after delivery."
"This is a source of your fluid loss after delivery."
A nurse is reinforcing teaching with a client about postpartum fatigue. Which of the following statements should the nurse include? A. "Strenuous exercise can help improve your sleep." B. "Try to take naps when your infant is napping." C. "Avoid consuming dairy products such as milk before bedtime." D. "You might want to ask family not to visit until you are more rested."
"Try to take naps when your infant is napping."
A nurse is reinforcing education about continuous heparin therapy with a client who is 18 hr postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching? A. "An adverse effect of this medication is drowsiness." B. "This medication will require frequent monitoring of WBC levels." C. "Use a soft toothbrush to gently brush your teeth." D. "Avoid taking acetaminophen while receiving this medication."
"Use a soft toothbrush to gently brush your teeth."
The nurse is reinforcing teaching with a client who is postpartum about the rubella vaccine. Which of the following statements should the nurse include? A . "You must not take this immunization if you've had the chickenpox." B. "You must not become pregnant for 28 days after receiving this immunization." C. "You must not breastfeed because the virus is passed in breastmilk." D. "You must not receive other vaccines at the same time as the rubella vaccine."
"You must not become pregnant for 28 days after receiving this immunization."
A nurse is reinforcing discharge teaching with a client who is postpartum. Which of the following statements should the nurse make? A. "You should notify the provider if your breasts feel full 5 days following delivery." B. "You should contact the procider if you do not have a bowel movement within 2 days." C. "You should notify the provider immediately if either of your legs becomes swollen." D. "You should contact the provider if you experience vaginal discharge lasting longer than a week."
"You should notify the provider immediately if either of your legs becomes swollen."
A nurse is reinforcing teaching to a client who is postpartum and has been prescribed warfarin therapy for a deep vein thrombosis. Which of the following instructions should the nurse include? A. "You will need to use a reliable form of contraception while on warfarin therapy." B. "You will need to take a baby aspirin every day while on warfarin therapy." C. "You will need to use formula instead of breast milk while on warfarin therapy." D. "You will need to massage your affected leg 3 times a day while on warfarin therapy."
"You will need to use a reliable form of contraception while on warfarin therapy."
A nurse is assisting with caring for a client who is 2 days postpartum. The client states, "My 4 year old old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. "Your son was probably not ready for toilet training and should wear training pants." B. "Your son is showing an adverse sibling response." C. "Your son may need counseling." D. "You should try sending your son to preschool to resolve the behavior."
"Your son is showing an adverse sibling response."
A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. Which of the following actions should the nurse plan to take when performing a fundal massage? (place them in correct order) A. Position a hand around the top of the client's fundus B. Place a hand just above the client's symphysis pubis C. Ask the client to lie on her back with her knees flexed D. Rotate the upper hand to massage the client's uterus E. Use slight downward pressure to compress the client's fundus
1. Ask the client to lie on her back with her knees flexed 2. Place a hand just above the client's symphysis pubis 3. Position a hand around the top of the client's fundus 4. Rotate the upper hand to massage the client's uterus 5. Use slight downward pressure to compress the client's fundus
A nurse is assisting with the care of a client who is postpartum and is receiving magnesium sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should the nurse identify as manifestations of magnesium toxicity? (select all that apply) A. Hyperreflexia B. Decreased respiratory rate C. Polyuria D. Decreased level of consciousness E. Double vision
1. Decreased respiratory rate 2. Decreased level of consciousness 3. Double vision
A nurse is assisting with care for a client who is 1 day postpartum. The nurse is collecting data for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply) A. Demonstrates apathy when the newborn cries B. Touches the newborn and maintains close physical proximity C. Views the newborn's behavior as uncooperative during diaper changing D. Identifies and relates newborn's characteristics to those of family members E. Interprets and relates newborn's characteristics to those of family members
1. Demonstrates apathy when the newborn cries 2. Views the newborn's behavior as uncooperative during diaper changing
A nurse is caring for a client during the postpartum period. Which of the following findings should the nurse expect during the first 24 hr following birth? (Select all that apply) A. Diuresis B. Soft, boggy uterus upon palpation C. Discharge of clear, yellow fluid from the breasts D. Lochia serosa E. Lower abdominal cramping
1. Diuresis 2. Discharge of clear, yellow fluid from the breasts 3. Lower abdominal cramping
A nurse is assisting with the care of a client who is 8 hours postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (select all that apply? A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°
1. Massage the fundus 2. Administer oxytocin with IV fluids 3. Insert an indwelling urinary catheter 4. Place the client in a lateral position with her legs elevated 30°
A nurse is assisting with caring for a client who is postpartum. Which of the following maternal characteristics should the nurse identify as the takin-in phase of maternal postpartum adjustment? A. The client is excited and talkative B. The client is independent with caring for baby C. The client requires assistance with meeting basic needs D. The client is eager to learn new tasks E. The client is desiring to take charge of their care
1. The client is excited and talkative 2. The client requires assistance with meeting basic needs
A nurse is preparing to reinforce education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information should the nurse include? (select all that apply) A. Use a perineal squeeze bottle to cleanse the perineum B. Sit on the perineum while resting in bed C. Apply a topical anesthetic cream or spray to the perineum D. Wipe the perineum thoroughly with a back and forth motion E. Apply cold or ice packs to the perineum
1. Use a perineal squeeze bottle to cleanse the perineum 2. Apply a topical anesthetic cream or spray to the perineum 3. Apply cold or ice packs to the perineum
A nurse is caring for a client who is 48 hr postpartum following a vaginal birth. Which of the following findings should the nurse report to the provider? (Select all that apply) A. Warm, tender area on the calf B. Orthostatic hypotension C. Moderate lochia rubra D. Dysuria E. Cracked nipples
1. warm, tender area on the calf 2. Dysuria 3. Cracked nipples
A nurse is assisting with the care of a client who is postpartum and is receiving lactated Ringer's 1,500 mL IV to infuse over 10 hr. The nurse should verify that the IV pump's settings will deliver how many mL/hr? (round to the nearest whole number)
150 mL/hr
A nurse is collecting data from a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus? A. 3 cm above the umbilicus B. 1 cm above the umbilicus C. 3 cm below the umbilicus D. 1 cm below the umbilicus
3 cm below the umbilicus
A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider?A. 2,000 mL urine since deliveryB. 3+ deep tendon reflexesC. Fundus at umbilicusD. Soft breasts
3+ deep tendon reflexes
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? A. Evidence of a possible vaginal hematoma B. An indication of a cervical or perineal laceration C. A normal postural discharge of lochia D. Abnormally excessive lochia rubra flow
A normal postural discharge of lochia
A nurse is caring for a client who is 12 hr postpartum. Which of the following interventions should the nurse implement? A. Encourage the client to use a hot pack on the perineum B. Administer ferrous sulfate orally C. Help the client apply a breast binder D. Administer Rh immune globulin
Administer ferrous sulfate orally
A nurse is collecting data from a client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take? A. Administer a tocolytic medication B. Apply a heating pad to the mid abdominal area C. Reassess the fundus in 2 hr D. Ambulate the client to the bathroom
Ambulate the client to the bathroom
A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A. Prepare to initiate a warm water sitz bath for the client's perineum B. Encourage the client to sit on a soft pillow C. Apply cold ice packs to the client's perineum D. Administer an acetaminophen suppository rectally
Apply cold ice packs to the client's perineum
A nurse is collecting data from a client who is 12 hours postpartum. Which of the following locations should the nurse expect to palpate the client's fundus? A. Approximately 1 cm above the umbilicus B. Approximately 2 cm below the level of the umbilicus C. At the symphysis pubis D. Directly between the symphysis pubis and umbilicus
Approximately 1 cm above the umbilicus
A nurse is caring for a client who is postpartum. After bringing the newborn back to the parent following an assessment, the parent immediately gives the infant to the grandparent. Which of the following actions should the nurse take? A. Make a referral to child protective services B. Ask the client about the family's cultural beliefs C. Take the newborn back to the nursey until the mother is ready to offer care D. Explain to the client the importance of caring for the newborn personally
Ask the client about the family's cultural beliefs
A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A. Reinforce the need to take antipsychotics as prescribed B. Ask the client if they have thoughts of harming themselves or their infant C. Monitor the infant for indications of failure to thrive D. Review the client's medical record for a history of bipolar disorder
Ask the client if they have thoughts of harming themselves or their infant
A nurse is collecting data from a client on the first postpartum day. Findings include a fundus that is firm and 1 fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take? A. Report the vital signs to the provider B. Massage the fundus C. Ask the client when she last voided D. Obtain a prescription for an oxytocic agent
Ask the client when she last voided
A nurse is caring for a client who is postpartum and reports abdominal pain due to flatus. Which of the following actions should the nurse take? A. Assist the client to ambulate in the hallway B. Encourage the client to increase fiber intake C. Administer a dose of laxative medication to the client D. Increase the client's fluid intake
Assist the client to ambulate in the hallway
A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first? A. Place the client's hands in warm water B. Administer an analgesic to the client C. Pour water from a squeeze bottle over the client's perineum D. Assist the client to the bathroom
Assist the client to the bathroom
A nurse is caring for a client who is 6 hr postpartum whose fundus is boggy and deviated to the right. Which of the following actions should the nurse take? A. Apply a heating pad to the client's abdomen B. Assist the client to the restroom to void C. Place client's hand in cool water D. Implement bedrest for the client
Assist the client to the restroom to void
A nurse is caring for a client who is 1 day postpartum following a cesarean birth. Which of the following laboratory findings should the nurse report to the provider? A. Hematocrit 34% B. White blood cell count 12,000/mm3 C. Blood glucose 50 mg/dL D. Erythrocyte sedimentation rate 33 mm/hr
Blood glucose 50 mg/dL
A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings is a sign of a potential complication? A. Dark red lochia with small clots B. Deep tendon reflexes 4+ C. Urine output since birth of 3,000 mL D. Soft pink hemorrhoids
Deep tendon reflexes 4+
A nurse is assisting with the care of a client who received carboprost tromethamine 2 hr ago for a postpartum hemorrhage. The nurse should identify that which of the following findings indicates an adverse effect of the medication? A. Diarrhea B. Hypotension C. Hyperreflexia D. Diaphoresis
Diarrhea *an adverse effect of carboprost tromethamine. Other adverse effects include fever, headache, nausea, vomiting, and chills
A nurse is reinforcing teaching about manifestations of postpartum depression with a client. Which of the following findings should the nurse include? A. Episodes of irritability without justification B. Sleeping more than 15 hours per day C. Desire to take care of the newborn with help D. Ability to verbalize negative feelings about the newborn
Episodes of irritability without justification
A nurse is collecting data from a client who is postpartum. The nurse should identify which of the following findings as a manifestation of endometritis? A. Foul-smelling lochia B. Fundus 2 cm above the umbilicus C. Decreased heart rate D. Dysuria
Foul-smelling lochia
A nurse is collecting data from a client who gave birth 18 hr ago. Which of the following findings should the nurse identify as an indication of a postpartum complication? A. Fundus is palpable at 2 cm above the umbilicus B. Temperature is 38 C (100.4 F) C. Lochia increases after breastfeeding D. The perineal pad contains several small blood clots
Fundus is palpable at 2 cm above the umbilicus *at the level of the umbilicus for 1st 24 hours postpartum then 1 cm above each day after that. higher than expected level could indicate uterine atony, which can result in maternal hemorrhage
A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth
Gestational diabetes
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. Tinnitus B. Numbness in the hand C. Headache D. Nasal stuffiness interfering with sleep
Headache
A nurse in a postpartum unit is caring for a client who has endometritis and is 48 hr postpartum following a cesarean birth. Which of the following findings should the nurse anticipate? A. WBC 8,000/mm3 B. Erythrocyte sedimentation rate 15 mm/hr C. Respiratory rate 18/min D. Heart rate 110/min
Heart rate 110/min *an elevated heart rate is an expected finding for a client with endometritis. Other manifestations are chills, fever, nausea, fatigue, pelvic pain, & lochia that has a foul odor
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as a manifestation of a urinary tract infection? A. Hematuria B. Temperature 39C (102.2 F) C. Diuresis D. 2 saturated perineal pads per hour
Hematuria
A nurse is assisting in the care of a client who is 24 hr postpartum. Which of the following findings should the nurse reports to the provider? A. Secretion of clear yellow fluid from the breast B. Increased uterine cramping while breastfeeding C. Hgb 7 g/dL D. WBC count 15,000/mm3
Hgb 7 g/dL
A nurse is assisting with the administration of methylergonovine for a client who is experiencing a postpartum hemorrhage. The nurse should monitor the client for which of the following adverse effects of this medication? A. Hypertension B. Uterine atony C. Sore throat D. Rhinitis
Hypertension
A nurse is caring for a client who is 3 days postpartum and has chosen to bottle feed the newborn. During examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following action should the nurse plan to take? A. Encourage the client to pump the breasts B. Instruct the client to take a warm shower twice per day C. Tell the client to massage the breasts D. Instruct the client to apply cold compresses
Instruct the client to apply cold compresses
A nurse is contributing to the plan of care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse recommend? A. Apply cold compresses to the affected extremity B. Massage the affected extremity C. Allow the client to ambulate D. Measure leg circumferences
Measure leg circumferences
A nurse is collecting data from a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use? A. Press down and forward with the hand that is placed on the base of the uterus B. Measure the height of the fundus in fingerbreadths in relation to the umbilicus C. Place the client in a semi-Fowler's position prior to checking the uterus D. Massage the fundus with gentle palpation until it becomes soft to touch
Measure the height of the fundus in fingerbreadths in relation to the umbilicus
A nurse is caring for a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse expect the provider to prescribe? A. Indomethacin B. Terbutaline C. Methylergonovine D. Betamethasone
Methylergonovine *used to treat Postpartum hemorrhage. It is an oxytocic medication that causes contraction of the smooth muscle of the uterus, which assists in decreasing the lochia. It should not be administered to clients who have preeclampsia or hypertension
A nurse is checking the fundus of a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document in the client's medical record? A. Moderate lochia rubra B. Excessive lochia serosa C. Light lochia rubra D. Scant lochia serosa
Moderate lochia rubra
A nurse is assisitng with the plan of care for a client who is postpartum and has a history of a pulmonary embolus. The provider has prescribed heparin therapy prophylactically. Which if the following interventions should the nurse recommend to include in the plan? A. Monitor aPTT and platelet count B. Perform fundal massage every 1 to 2 hours C. Assist the client with using a breast pump until therapy is discontinued D. Maintain strict bedrest
Monitor aPTT and platelet count
A nurse is collecting data from postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take? A. Massage the fundus B. Instruct the client to empty her bladder C. Notify the provider D. Teach the client how to perform a sitz bath
Notify the provider
A nurse is caring for a client who is postpartum. The client suddenly appears restless and reports an inability to catch her breath. Which of the following actions should the nurse take? A. Evaluate vital sign trends, focusing on blood pressure history. B. Review admission laboratory values, specifically hematocrit C. Notify the unit charge nurse and the rapid response team D. Ask the client about pain, urination, and lochia characterisitics
Notify the unit charge nurse and the rapid response team
A nurse is caring for a client who is postpartum and has endometritis. Which of the following findings should the nurse report to the provider? A. Foul-smelling lochia B. Uterine pain with palpation C. Temperature 38.1 C (100.6 F) D. Oxygen saturation 93%
Oxygen saturation 93%
A nurse is assisting with the care of a postpartum client who has preeclampsia and excessive bleeding. The nurse should plan to administer which of the following medications? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine
Oxytocin
A provider is assisting with the care of a client who is postpartum following a vaginal delivery. The nurse should identify that which of the following circumstances is a risk factor for postpartum hemorrhage? A. Oxytocin-induced labor B. Obligohydramnios C. Small fetus D. Gravida 1
Oxytocin-induced labor
A nurse is assisting with performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus. B. Palpate the fundus of the uterus C. Grasp lower uterine segment between thumb and fingers D. Stand facing client's feet with fingertips outlining cephalic prominence
Palpate the fundus of the uterus
A nurse is assisting with the care of a client who has a precipitous delivery. Which of the following items of data is the nurse's priority during the fourth stage of labor? A. Obtaining the client's temperature B. Inspecting the client's perineum C. Palpating the client's fundus D. Checking the client for hemorrhoids
Palpating the client's fundus
A nurse is collecting data from a client who is 48 hours postpartum. Which of the following findings should the nurse report to the provider? A. The fundus is firm after palpation with moderate lochia noted B. Pelvic and uterine pain is present while at rest C. Urination is documented every 2 to 4 hours D. The client reports difficulty sleeping the previous night
Pelvic and uterine pain is present while at rest
A nurse is caring for a client who delivered vaginally 6 hr ago. Which of the following findings should the nurse expect to report to the provider? A. Labial edema B. Fundus firm at the umbilicus C. WBC count 15,000/mm3 D. Perineal pad soaked in 15 min
Perineal pad soaked in 15 min
A nurse is assisting with the care of a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations?A. Postpartum fatigueB. Postpartum psychosisC. Letting-go phaseD. Postpartum blues
Postpartum blues
A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? A. Encourage the client to ambulate B. Provide a sitz bath with warm water C. Instruct the client to perform Kegel exercises D. Apply anesthetic cream topically each hour while the client is awake
Provide a sitz bath with warm water
A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus and excessive vaginal bleeding. Which of the following actions should the nurse take first? A. Provide fundal massage for the client B. Insert an indwelling urinary catheter for the client C. Administer methylergonovine IM to the client D. Administer oxygen via nonrebreather face mask to the client
Provide fundal massage for the client
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. Blood pressure 139/89 mmHg B. Deep tendon reflexes 2+ C. Report of blurred vision D. Bilateral, dull headache
Report of blurred vision
A nurse assisting with the plan of care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention? A. Withhold analgesics to prevent urinary retention B. Run water in the sink while the client sits on the toilet C. Perform Crede's maneuver every 4 hours D. Restrict oral hydration
Run water in the sink while the client sits on the toilet
A nurse is reinforcing teaching with a client who is postpartum and has a hearing impairment. Which of the following techniques should the nurse use? A. Raise voice volume B. Stand in front of a light or window C. Sit at the client's eye level D. Ask client to read educational material after the teaching
Sit at the client's eye level
A nurse is reinforcing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? A. Scant, nonodorous white vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipple with cracks and fissures D. Decreased response with sexual activity
Sore nipple with cracks and fissures
A nurse is reinforcing teaching about parental attachment with a client who is postpartum. Which of the following client behaviors indicates an understanding of the teaching? A. The client primarily touches the newborn with her fingertips B. The client does not critique the newborn's features and body parts C. The client has given the newborn a name D. The client is quiet with a blank facial expression
The client has given the newborn a name
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. The client's temperature measures 101.9°F (38.8°F) 3 hours following delivery B. Lochia is red with small clots and mucus 2 days after delivery C. Client reports abdominal pain 48 hours after delivery when the newborn is breastfeeding. D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery
The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery
A nurse is reinforcing about the process of involution with a client who is postpartum. Which of the following pieces of information should the nurse provide? A. The fundus is approximately 2 cm (0.79 in) above the level of the umbilicus at the end of the third stage of labor B. The fundus is approximately 3 cm (1.18 in) above the umbilicus within hour after delivery C. The fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum D. The fundus is not palpable abdominally at 2 weeks postpartum
The fundus is not palpable abdominally at 2 weeks postpartum
A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. The newborn would benefit from skin-to-skin contact in a quiet environment B. The newborn's blanket should be removed so her movements will not be restricted C. The newborn's hat should be removed to avoid overheating D. The newborn should be discouraged from sucking on her hand since this habit can interfere with feeding
The newborn would benefit from skin-to-skin contact in a quiet environment
A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findings should the nurse expect? A. Saturation of one perineal pad every 15 min B. Fundus 2 cm above the umbilicus C. Temperature of 39 C (102.2 F) D. Urine output of 3,000 in 24 hr
Urine output of 3,000 in 24 hr
A nurse on a postpartum unit is contributing to the discharge teaching plan for a client. Which of the following instructions should the nurse suggest for the plan? A. Apply powder to the newborn's skin after baths B. Use a firm mattress in the newborn's crib C. Cover the newborn with a crib comforter D. Place the newborn on their stomach to sleep
Use a firm mattress in the newborn's crib *decreases the risk of SIDS
A nurse is caring for a client who has preeclampsia and is postpartum. Which of the following actions should the nurse implement when measuring the client's blood pressure? A. Encourage the client to take a walk in the halls prior to measuring blood pressure B. Hold the client's arm above heart level during the measurement C. Choose a cuff that covers 50% of the client's upper arm D. Use the Korotkoff phase V to record the diastolic value
Use the Korotkoff phase V to record the diastolic value
A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following nutrients should the client increase her intake of while breastfeeding? A. Vitamin C B. Iron C. Folate D. Calcium
Vitamin C
A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings should the nurse identify as an indication of infection? A. BUN 15 mg/dL B. WBC 35,000/mm3 C. Urine specific gravity 1.025 D. Hgb 10 g/dL
WBC 35,000/mm3
A nurse is reinforcing teaching about newborn baths with a client who is 2 days postpartum. Which of the following pieces of information should the nurse include? A. Wash the newborn's face with plain warm water B. Wash the newborn's hair before the rest of the body C. Bathe the newborn once each day D. Bathe the newborn immediately after a feeding
Wash the newborn's face with plain warm water
A nurse in antepartum clinic is collecting data from a client who is 2 weeks postpartum and reports vaginal discharge. Which of the following discharge characteristics should the nurse expect? A. Dark red uterine discharge B. Pinkish-brown vaginal discharge C. Yellowish-white uterine discharge D. Bright red vaginal discharge
Yellowish-white uterine discharge
A nurse is reinforcing teaching about breastfeeding with a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include? A. Feed the newborn for 5 minutes on each breast B. Newborns are expected to lose up to 15% of their birth weight C. Ensure the newborn's mouth covers the nipples and areola D. Provide a pacifier to the newborn between feedings starting 3 days after birth
ensure the newborn's mouth covers the nipples and areola
A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take? A. Place the client in high-Fowler's position B. Administer terbutaline subcutaneously C. Apply oxygen at 2 L/min via nasal cannula D. Insert an indwelling catheter
insert an indwelling catheter *to monitor output closely. Decreased kidney perfusion caused by shock can lead to oliguria
A nurse is caring for a client who is 2 hours postpartum. The nurse notes that the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first? A. Check for a full bladder B. Massage the fundus C. Measure vital signs D. Administer carboprost IM
massage the fundus
A nurse is assisting with the care of a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take? A. Saline lock the IV catheter B. Provide oxygen via nasal cannula C. Elevate the client's legs to a 30° angle D. Place the client in a semi-Fowler's position
provide oxygen via nasal cannula*
