pn NCLEX postpartum
and your mother is attempting to breastfeed for the first time. The nurse notices that they client has inverted nipples. Which nursing action can the nurse take to assist the client in breastfeeding the newborn
provide breast shield in assisting mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp
the nurse palpates the furnace and checks the character of the lochia of a postpartum client who is in the fourth stage of Labor. Which lochia characteristic should the nurse expect to note
red
A postpartum client with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse should make which response to the client?
"You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus."
it has been 12 hours since the delivery of a newborn. The nurse assesses the mother for the process of evolution and documents that it is progressing normally when palpation of the client's fundus is noted at which level
1
the nurse is assisting in developing a plan of care for a cloud preparing to breastfeed. And planning care which factor is significant in teaching a client to breastfeed
A positive nurse client relationship
The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first?
Assist the client to the bathroom to void and then reassess the fundus.
The nurse has a prescription to give a dose of Rho(D) immune globulin (RhoGAM) to a client who has delivered an infant. The nurse understands that this medication will prevent the next infant from experiencing which complication?
Being affected by Rh incompatibility
A client arrives to the postpartum unit following the delivery of her newborn premature infant. On data collection, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate?
Covering her with a warm blanket
The postpartum nurse is collecting data from a client who delivered a viable newborn 2 hours ago. The nurse palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should the nurse expect to note at this time?
Dark red lochia
The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms?
Dyspnea, tachypnea, and tachycardia
the nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching
I can resume sexual activity at any time
a postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement
I don't need birth control because I will be breastfeeding
the nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching
I will change the perineum pads 3 times a day
the nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures that will provide Comfort. Which statement by the mother indicates an understanding of these measures
I will massage the breast before feeding to stimulate let down
When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which nursing action is appropriate?
Notify the registered nurse (RN).
The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action?
Prepare an ice pack for application to the area.
the goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. And planning care to assist in meeting this goal the nurse should perform which action
administer anticoagulants as prescribed
the nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which side noted in the mother would indicate an early sign of excessive blood loss and shock
an increase in the pulse rate from 80 to 102 beats per minute
the nurse is caring for a client during the immediate recovery phase or fourth stage of Labor. Which action is important for the nurse to take at this time
check the uterine fundus and lochia
the nurse caring for a woman who has delivered a baby after pregnancy with a placenta previa. Which complication would the client be at risk for
postpartum hemorrhage
A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. Which should the nurse tell the client?
"Breast-feed from the left breast and gently pump the right breast."
The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which?
Bladder distention
the nurse is providing nutritional counseling to a new mother who is breastfeeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount
500 calories per day
the nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed which amount
8 pads per day
The nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage. The nurse plans care based on which information related to the condition?
Fewer muscle fibers in the lower segment of the uterus will result in poor contractions.
The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate?
Gather data from the client and spouse about the perception of the event.
The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms?
Hematuria, ecchymosis, and epistaxis
A postpartum client suspected of having an infection is informed that she will be unable to have the newborn present in the room with her. The nurse plans care, knowing that which problem is the highest priority at this time?
Risk of ineffective bonding between the mother and newborn
The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding should indicate which accurate interpretation to the nurse?
This may be a sign of hemorrhage or shock.
the nurse is caring for a postpartum client. At 4 hours postpartum the closet temperature is 102°F. which is the appropriate nursing action
notify the registered nurse who will then contact the healthcare provider
the nurse is preparing a list of self care instructions for a postpartum client who has been diagnosed with mastitis. Which instruction should be included on the list
rest during the acute phase wear a supportive non underwire bra maintain a fluid intake of at least 3000 ml continue to breastfeed if the breast are not too sore
a client experiences subinvolution during the puerperium. the nurse recalls that which factors are most common causes for this occurrence
retained placental fragments and infections
oxytocin is prescribed to be administered intravenously to client after cesarean delivery. The nurse understands that which is the action of the medication
to stimulate the uterus to contract this reducing possible blood loss
a new mother is seen in the healthcare clinic 2 weeks after the birth of a healthy newborn. They mother says that she feels as though she has the flu and complaints of fatigue and aching muscles. On further data collection and there's no it's a localized area of redness on the left breast in the mother is diagnosed with mastitis. The brother asked the nurse how they condition occurs. Which nursing response is appropriate
the infection can occur at any time during breastfeeding
The nurse is reinforcing instructions to a client who had an episiotomy during the birthing process. Which statement by the client would indicate a need for further teaching?
"I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115° F."
The nurse reinforces home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?
"If I develop a fever, I will call my doctor."
Oxytocin (Pitocin) is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication?
Uterine contractions
the nurse in the postpartum unit notes the result of a rubella titer drawn on a postpartum client during the antepartum is 1:8. which should the nurse anticipate to be prescribed by the healthcare provider
administration of a subcutaneous rubella virus vaccine
the nurse is assigned to care for a client after a cesarean section. To prevent thrombophlebitis the nurse should encourage the woman to take which priority action
ambulate frequently
the nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery
an adolescent experiencing an emergency cesarean delivery for fetal distress
a postpartum client who delivered at 32 weeks of gestation would like to breastfeed her preterm infant. At this time the infant is receiving tube feedings only. What is the nurses best response to the mother
you can begin pumping as soon as possible after delivery with an electric breast pump
the nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery would support this diagnosis
abdominal tenderness and chills
the nurse is checking lochia discharge on a clot in the immediate postpartum. And notes that the lochia is bright red and contain some small clots. Which interpretation should the nurse make about this finding
is normal
a client had a cesarean delivery with a low transverse uterine incision. Which is the benefit of this type of incision
it allows a vaginal birth after cesarean to be possible in a subsequent pregnancy
the nurse caring for breastfeeding postpartum client plans to include Ed voidance of soaps on the nipples, frequent changing of breast pets, and intermittent exposure of nipples to the air. These interventions are implemented to prevent which complication
mastitis
a delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus expecting to note which uterine fundus position
at the level of the umbilicus
the nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the healthcare provider
pain, redness, or swelling in the breast
the nurse is reinforcing instructions to a mother who is bottle feeding a baby who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching
I should have avoided wearing a bra
the nurse is caring for a client who delivered a healthy newborn via vaginal delivery. And episiotomy was performed and the woman has developed a wound infection at the episiotomy site. The nurse reinforces instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further teaching
I need to ask delete my infant for 48 hours after starting the antibiotic
the nurse has reinforce instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she makes which statement
I should alternately contract and relax muscles of the perineal area
The nurse is assisting in administering beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse understands that the medication should be administered by which route?
Intratracheal
A postpartum client asks the nurse when she may resume sexual activity. Which response should the nurse give to the client?
Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped.
which safety measure that should be implemented when working in the newborn Nursery
adhere to standard precautions the parent should be instructed to not release their infant to anyone wearing improper identification the mother should be fingerprinted and the infant should be foot printed on the identification card before removing the infant from the delivery room
a new mother attempting breastfeeding for the first time has development status. She states my breasts look terrible and I think that I will stop breastfeeding. The nurse plans care knowing that the client is concerned about which problem
body image
a pregnant client test positive for Hepatitis B virus and a client asked the nurse whether she will be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client
breastfeeding is allowed once the baby has been vaccinated
which nursing action would decrease the discomfort of an episiotomy
performing sitz bath applying ice packs to the perineum for the first 12 to 24 hours
the nurses monitoring a new mother for signs of postpartum depression. Which observations in the mother indicate the need for further data collection related to this form of depression
shows a lack of interest in eating lacks the ability to concentrate on task complains of feeling tired all of the time
a 45 year old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been Complicated by thrombophlebitis in her left leg. She cries frequently and request to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified postpartum Blues because of which situation
decline is required to stay on bed rest
the nurse is collecting data on a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints the nurse should check which as a priority
vulva for a hematoma
the nurse receives a report at the beginning of shift regarding at client within intrauterine fetal demise. Which signs/symptoms should the nurse expect to note when collecting data on the client
regression of pregnancy symptoms and absence of fetal heart tones
a client is admitted to the labor and delivery Suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response
request to hold the infant following delivery
after a precipitous delivery the nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which action first to help the woman process what has happened
support the mother no matter what her reaction is to the newborn
after surgical evacuation and repair of a vaginal hematoma a 3-day postpartum mother is discharged. The nurse determines that the mother needs further discharge instructions if the new mother makes which statement
the only medications that I will take are prenatal vitamins and stool softeners
the nurse is assisting in developing a plan of care for a client in the fourth stage of Labor who received an epidural. Which problem is most likely to occur during this stage
urinary retention caused by the loss of sensation to void and Rapid bladder filling
the new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother would indicate a need for further teaching
my left breast is sore, so I will offer only my right breast frequently for breastfeeding
a client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and respiratory rate is elevated. The nurse suspects a pulmonary embolism which should be the initial nursing action
prepare to administer oxygen at 8 to 10 by tight face mask
after delivery the nurse checks the height of the uterine fundus. Which position of the Furnace should the nurse expect to note
at the level of the umbilicus
the parents of a neonate who is not circumcised request information on how to clean a newborn's penis. Which is the correct response for the nurse to make to the parents
avoid retracting the foreskin to clean the glands because this may cause adhesions
a client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness which action should the nurse suggest to the client
begin feeding on the less sore nipple
a pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable the nurse should take which approach as the first step to support the client physiologically
collect data regarding how the client receive the event
a postpartum nurse obtain C vital signs on a mother who delivered a healthy newborn 2 hours ago. Then mothers temperature is 100 °F. what is the initial nursing action
encourage oral fluid intake
the nurse is preparing to care for a woman in the immediate postpartum. Who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals
every 15 minutes for the first hour then every 30 minutes for the next 2 hours
the nurse is reviewing the procedure of vitamin K injection in a newborn. Which information is included in the procedure
inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute
the nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate
instructing mother to request help in getting out of bed
the postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks see mothers fundus and notes that it is firm. On review of the mothers record the nurse also notice that it episiotomy was perform. Which determination should the nurse make based on this information
bright red bleeding is abnormal and should be reported
a client has had a midline episiotomy. In relation to clients with other types of episiotomies the nurse anticipates that the client will generally experienced which
less pain
The nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs?
Checks the calf areas for redness or swelling
the nurse is reinforcing instructions to a mother who is bottle feeding a baby who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching
I should avoid wearing a bra at this time
on the second postpartum day at mother complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis and the results indicate the presence of a urinary tract infection. The nurse reinforces instructions to the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further teaching
foods and fluids that will increase your and alkalinity should be consumed
the nurse provides explanation to a client prescribed methylergonovine maleate in the imminent postpartum period. which statement made by the client demonstrates understanding of the rationale for administration
it will help prevent and control bleeding if it occurs
in formulating the plan of care which problem is most important to address for postpartum client who has expressed concerns about not knowing how to care for her newborn
lack of knowledge regarding ability to care for the newborn
