WK13/MN Success/ High Risk Postpartum

63. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client? 1. The woman should never be left alone with her infant. 2. Symptoms rarely last more than one week. 3. Clinical response to medications is usually poor. 4. The woman must have her vitals assessed every two days.

***1. It is essential that the client never be left alone with her baby. 2. The statement is untrue. There is no set time frame for the resolution of the symptoms of postpartum psychosis. 3. Clinical response to medications is usually quite good. 4. The client's vital signs need not be assessed frequently

79. A woman is receiving Paxil (paroxetine) for postpartum depression. In order to prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following? 1. Alcohol. 2. Grapefruit. 3. Milk. 4. Cabbage.

***1. Alcohol. Clients should be warned about consuming alcohol when taking Paxil. 2. Grapefruit is not contraindicated for clients who have been prescribed Paxil.

71. The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen (hPL). 4. Human chorionic gonadotropin (hCG).

**3. The drop in human placental lactogen (hPL) is related to the glucose level. The hormone hPL is an insulin antagonist. Throughout pregnancy, the insulin needs of type 1 diabetics rise incrementally as the levels of hPL in the bloodstream rise. Once the placenta is birthed, however, the levels of hPL drop precipitously.

52. A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply. 1. Look up the client's blood type in the chart. 2. Check the client's arm bracelet. 3. Check the blood type on the infusion bag. 4. Obtain an infusion bag of dextrose and water. 5. Document the time the infusion begins.

1, 2, 3, and 5 are correct. 1. The nurse must check the client's blood type. 2. The nurse must check the client's name by checking the bracelet and asking the client her name. 3. The nurse must compare the client's blood type with the blood type on the infusion bag. 5. The time the infusion begins and ends must be documented 4. The nurse must obtain an infusion of normal saline, not dextrose and water.

12. The nurse should expect to observe which behavior in a 3-week multigravid postpartum client with postpartum depression? 1. Feelings of infanticide. 2. Difficulty with breastfeeding latch. 3. Feelings of failure as a mother. 4. Concerns about sibling jealousy.

3. Mothers who experience postpartum depression often do feel like failures.

1. A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time? 1. "Monitor your blood glucose five times a day until your 6-week check-up." 2. "I will teach you how to inject insulin before you are discharged." 3. "Daily exercise will help to prevent you from becoming diabetic in the future." 4. "Your baby should be assessed every 6 months for signs of juvenile diabetes."

3. This is an appropriate statement to make. "Daily exercise will help to prevent you from becoming diabetic in the future."

58. A client is receiving an IV heparin drip at 16 mL/hr via an infusion pump for a diagnosis of deep vein thrombosis. The label on the half LITER bag of D5W indicates 25,000 units of heparin have been added. How many units of heparin is the client receiving per hour? __________ units per hour.

800 units/hour

48. Which of the following comments suggest that a client, whose baby was born with a congenital defect, is in the bargaining phase of grief? 1. "I hate myself. I caused my baby to be sick." 2. "I'll take him to a specialist. Then he will get better." 3. "I can't seem to stop crying." 4. "This can't be happening."

2. "I'll take him to a specialist. Then he will get better." This client is exhibiting the bargaining stage of grief.

37. Cloxacillin 500 mg by mouth four times per day for 10 days has been ordered for a client with a breast abscess. The client states that she is unable to swallow pills. The oral solution is available as 125 mg/5 mL. How many mL of medicine should the woman take per dose? ______ mL per dose.

20 mL per dose

29. A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery while the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for? 1. Pruritus. 2. Nausea. 3. Postural headache. 4. Respiratory depression.

3. The client who has had the spinal anesthesia is much more likely to develop a postural headache than a client who had epidural anesthesia.

78. On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client? 1. "Have you ever had anesthesia before?" 2. "Do you have any allergies?" 3. "Do you scar easily?" 4. "Are there many stairs in your home?"

4. "Are there many stairs in your home?" The client has had major surgery. The client will need some assistance when she returns home, especially if she has a number of stairs to climb.

25. A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus? 1. Abdominal striae. 2. Oliguria. 3. Omphalocele. 4. Absent bowel sounds.

4. An absence of bowel sounds may indicate that a client has a paralytic ileus.

59. A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved? 1. Moderate lochia flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus above the umbilicus.

****A moderate lochia flow would indicate that the action was successful

23. A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediolateral episiotomy. The client is at risk for EACH of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain.

1. Because the baby has Down syndrome, this is an appropriate nursing diagnosis, but it is not the highest priority diagnosis. **2. Fluid volume deficit. This is the priority nursing diagnosis. Because the baby is macrosomic, the client is high risk for uterine atony that could lead to heavy vaginal bleeding possibly resulting in fluid volume deficit. 3. Although the client is at high risk for infection, it is not highest priority. Infections take time to develop and this client is only 10 minutes postdelivery. 4. Although the client is at high risk for pain, especially from the episiotomy, this is not the highest priority nursing diagnosis.

24. A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

1. Foul-smelling lochia is a sign of endometritis.

3. A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? 1. Hyperthermia, vomiting, and diarrhea. 2. Hypotension and respiratory collapse. 3. Anasarca and fluid volume overload. 4. Palpitations, anxiety, and insomnia.

1. Hemabate can cause nausea, vomiting, diarrhea, and hyperthermia.

32. A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful? 1. The mother's nipples are soft to the touch. 2. The baby swallows after every 5th suck. 3. The baby's pre- and postfeed weight change is 20 milliliters. 4. The mother squeezes her nipples during manual expression.

1. If the woman has manually removed milk from her breasts, her nipples will soften to the touch.

2. A client is receiving a blood transfusion after the delivery of a placenta acreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion? 1. "My lower back hurts all of a sudden." 2. "My hands feel so cold." 3. "I feel like my heart is beating fast." 4. "I feel like I need to have a bowel movement."

1. Sudden lower back pain is a sign of a transfusion reaction.

51. A client, who had no prenatal care, delivers a 10 lb 10 oz-baby boy whose serum glucose result 1 hour after delivery was 20 mg/dL. Based on these data, which of the following tests should the mother have at her 6-week postpartum check up? 1. Glucose tolerance test. 2. Indirect Coombs' test. 3. Blood urea nitrogen (BUN). 4. Complete blood count (CBC).

1. The client should have a glucose tolerance test done at about 6 weeks' postpartum. Women who give birth to hypoglycemic and/or macrosomic babies are at increased risk of developing type 2 diabetes. Normal newborn Glucose: 40mg/dL on 1st day and >40-50mg/dL thereafter.

30. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 1. Hallucinations. 2. Polyphagia. 3. Induced vomiting. 4. Weepy sadness.

1. The client with postpartum psychosis will experience hallucinations.

13. Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

1. The client would be expected to complain of pain.

31. The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? 1. Gently massage the areas toward the nipple especially during feedings. 2. Apply ice to the areas between feedings. 3. Bottlefeed for the next twenty-four hours. 4. Apply lanolin ointment to the areas after each and every breastfeeding.

1. This answer is correct. She should gently massage the area toward the nipple. A client who palpates a tender, hard nodule in her lactating breast is experiencing milk stasis. The stasis may be related to a blocked milk duct. It is very important that the woman gently massage the nodule while applying WARM soaks and feeding her baby to prevent mastitis from developing.

26. A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for last 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.

1. Urine output 200 mL for last 8 hours. This output is below the accepted minimum for 8 hours. The accepted output is 30 mL/hr. Because this is a postpartum client, the nurse would expect high urinary outputs. Postpartum clients often have slowed heartbeats.

68. A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding? 1. The mother states, "I'm so tired. Please feed the baby in the nursery for me." 2. The mother states, "Her eyes look like mine, but her chin is her Dad's." 3. The mother says, "We have decided to name her Sarah after my mother." 4. The mother says, "I breastfed her. I still need help swaddling her, though."

1. This statement by the mother may be a true statement, but it may communicate the mother's difficulty with accepting her baby.

18. The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0ºF, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings? 1. Temperature is elevated, a sign of infection. 2. Pulse is too low, a sign of vagal pathology. 3. Respirations are too low, a sign of medication toxicity. 4. Blood pressure is elevated, a sign of preeclampsia.

1. This temperature elevation does not indicate infection. 2. A low pulse rate is expected in the early postpartum period. **3. The respiratory rate of 12 is well below normal. Peripartum clients' respiratory rates average 20 rpm. 4. Although the systolic pressure is slightly elevated, a BP of 130/80 is within normal limits.

53. A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? 1. G1P0000, delivery at 29 weeks' gestation. 2. G2P1001, prolonged first stage of labor. 3. G2P0010, delivery by cesarean section. 4. G3P0200, delivery of 2200-gram neonate.

2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH).

21. A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 3. Ask the woman if she would like the doctor to prescribe a sedative for her. 4. Remove the baby from the delivery room as soon as possible.

2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket as if he/she were a viable baby. This response is correct.

9. The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug? 1. Monitor the urinary output hourly. 2. Supervise while the woman holds her newborn. 3. Position the woman slightly elevated on her left side. 4. Ask any visitors to leave the room.

2. Supervise while the woman holds her newborn. This is an appropriate action. Benadryl is an antihistamine. One of the most common SE of benadryl and morphine is sedation.

5. The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? 1. Massage the uterus. 2. Notify the obstetrician. 3. Administer an oxytocic as ordered. 4. Assist the client to the bathroom.

2. It is important for the nurse to notify the physician. The client is bleeding more than she should after the delivery. The nurse must notify the practitioner for assistance because the bleeding may be due to a tissue laceration.

72. A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding? 1. Have the woman wean the baby to formula. 2. Have the baby stay in the hospital room with the mother. 3. Have the woman pump and dump her milk for two weeks. 4. Have the baby bottlefed milk that the mother has stored.

2. Optimally, the baby should stay in the hospital room with the mother.

40. A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk? 1. Hemorrhage. 2. Stroke. 3. Endometritis. 4. Hematoma.

2. The client is at high risk for stroke if a clot should travel to the brain through the vascular tree.

41. A mother, G4P4004, is 15 minutes postpartum. Her baby weighed 4595 grams at birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis.

2. The client should be monitored carefully for signs of postpartum hemorrhage. An average size baby weighs 2,500-4,000 grams. The baby in scenario is macrosomic. As a result, the mother's uterus has been stretched beyond its expected capacity. In addition, this client is a "grand multipara". The client is at high risk for uterine atony, which could result in a PPH.

17. A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform? 1. Cover the wound with sterile wet dressings. 2. Notify the surgeon. 3. Elevate the head of the client's bed slightly. 4. Flex the client's knees.

2. The highest priority action is to notify the surgeon. 1. After the surgeon is notified, the nurse should stay with the patient while another staff member gathers supplies, including a suture removal kit and personal protective equipment as well as sterile saline solution and a large syringe. 3. After the surgeon has been notified the nurse should elevate the client's bed slightly. 4. After the surgeon has been notified the nurse should flex the client's knees slightly.

33. A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6˚F, P 72, R 20, BP 150/100, and her reflexes are 4. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes.

2. The nurse should notify the physician of the signs of preeclampsia.

6. A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104. 2. Urinary output 240 cc/12 hr. 3. Blood pressure 160/120. 4. Temperature 100ºF.

2. The urinary output is the likely cause of the client's changes. The hourly output for this client is 20 mL/hr. This is well below the minimum of 30 mL/hr. Because the medication is excreted via the kidneys, when a client's output is low, the concentration of the medication can increase to toxic levels in the bloodstream. The client is exhibiting signs of magnesium toxicity.

14. A breastfeeding woman calls the pediatric nurse with the following complaint: "I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I give the baby until I get better?" Which of the following replies by the nurse is appropriate at this time? 1. "Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes." 2. "Don't forget to pump your breasts every 3 hours while you are feeding the baby the prescribed formula." 3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." 4. "In addition to feeding the baby formula, you should wear a surgical face mask when you are around him."

3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." This response by the nurse is appropriate. First, the baby has already been exposed to the mother and will continue being exposed to her even if she switches to formula. More important, however, is the fact that the mother will produce antibodies that will be consumed by the baby in the breast milk.

8. The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement? 1. Maintain client in left lateral recumbent position. 2. Teach sitz bath use on second postoperative day. 3. Perform active range of motion exercises until ambulating. 4. Assess central venous pressure during first postoperative day.

3. Active range of motion exercises will help to prevent thrombus formation in C/section patients.

20. In which of the following situations should a nurse report a possible deep vein thrombosis (DVT) even when the woman has a negative Homan's sign? 1. The woman complains of numbness in the toes and heel of one foot. 2. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. 3. One of the woman's calves is swollen, red, and warm to the touch. 4. The veins in the ankle of one of the woman's legs are spider-like and purple.

3. Even with a negative Homan's sign, these findings—swelling, redness, and warmth—indicate presence of a DVT.

76. Which of the following is a priority nursing diagnosis for a woman, G10P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration is comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role.

3. Fluid volume deficit related to blood loss is the priority nursing diagnosis.

19. The nurse is discharging four Rh-negative clients from the maternity unit. The nurse knows that further teaching is needed when the client who had which of the following deliveries asks why she has not received her RhoGAM? 1. Abortion at 10 weeks' gestation. 2. Fetal demise at 24 weeks' gestation. 3. Birth of Rh-negative twins at 35 weeks' gestation. 4. Delivery of a 40-week-gestation Rh-positive baby.

3. The client does not need a RhoGAM injection after the delivery of Rh negative twins.

28. A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time.

3. The fundal response indicates that the medication was effective in contracting the uterus.

44. A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? 1. Engorgement. 2. Mastitis. 3. Blocked milk duct. 4. Low milk supply.

4. The nurse would expect that the woman would have a low milk supply. The placenta produces the hormones of pregnancy, including estrogen and progesterone. When fragments are retained, those hormones are still being produced. Estrogen inhibits prolactin, which is the hormone of lactogenesis, or milk production. They are also at risk for PPH and intrauterine infections.

56. A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first? 1. Give two breaths. 2. Discontinue medications. 3. Call a code. 4. Check carotid pulse.

3. The nurse should call a code first. The nurse should call a code as soon as he/she discovers a client who is nonresponsive. Immediately after calling the code, the nurse should stop the medications, begin rescue breathing, and provide chest compressions, if necessary until the code team arrives.

27. A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery complains of burning on urination. 2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO3 from cesarean delivery complains of firm and painful breasts.

3. This client should be assessed first. The hemoglobin level is well below normal.

42. A client who received a spinal for her cesarean delivery is complaining of pruritus and has a macular rash on her face and arms. Which of the following medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Zofran (ondansetron). 3. Compazine (prochlorperazine). 4. Benadryl (diphenydramine).

4. Benadryl is an antihistamine. It is the drug of choice for this client who has pruritus and a rash.

11. A rubella nonimmune, breastfeeding client has just received the rubella vaccine. Which of the following side effects should the nurse warn the client about? 1. The baby may develop a rash a week after the shot. 2. The baby may temporarily reject the breast milk. 3. The mother's milk supply may decrease precipitously. 4. The mother's joints may become painful and stiff.

4. One out of 4 women complains of painful and stiff joints after receiving the injection.

22. A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client? 1. Strongly advise the client to breastfeed her baby. 2. Perform hourly incentive spirometer respiratory assessments. 3. Suggest that the nursery nurse feed the baby in the nursery. 4. Provide the client with supervised instruction on baby care skills.

4. Providing instruction on baby care skills is a very important action for the nurse to perform. Babies of mothers who are addicted to illicit drugs go through withdrawal period and, because of the addiction, often have very disorganized behavior patterns. The nurse must provide guidance for the primipara regarding care of her difficult child, especially because she already has poor judgement.

50. A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose? 1. Vitamin K. 2. Protamine. 3. Vitamin E. 4. Mannitol.

***2. Protamine is the antidote for heparin overdose. 1. Vitamin K is the antidote for Coumadin (warfarin) overdose, not for heparin overdose. 3. Vitamin E is not correct. 4. Mannitol is not correct.

39. The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching in the hospital was successful? 1. The client is breastfeeding her baby every two hours. 2. The client is using a diaphragm for family planning. 3. The client is taking her temperature every morning. 4. The client is seeking care for a recent weight loss.

***4. The client should seek care for a recent weight loss. This may be a symptom of full-blown AIDS. 1. Breastfeeding is contraindicated when a mother is HIV positive. 2. It is recommended that HIV-positive clients use condoms for family planning. 3. It is unnecessary to take her temperature every morning. If she should develop a fever, she should seek medical assistance as soon as possible, however. The nurse must review the actions that clients should take after dx which includes: taking all meds, bottle feeding, using condoms, and reporting any health changes such as weight loss or the appearance of thrush.

7. A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? 1. Place the client flat in bed. 2. Assess for dependent edema. 3. Auscultate lung fields. 4. Check patellar reflexes.

3. It is important for the nurse to auscultate the client's lung fields every 4 hours to assess for rales.

45. The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time? 1. Advise the woman to wash the area with soap to prevent mastitis. 2. Provide the woman with a tube of topical lanolin. 3. Remind the woman that the baby can become sick if he drinks the blood. 4. Get the woman an order for a topical anesthetic.

**2. A small amount of lanolin should be applied to the nipple after each feeding. Using lanolin on the breasts is a type of moist wound healing. The lanolin is soothing and allows the nipple to heal without a scab developing. 1. The woman should not wash with soap. Soaps destroy the natural lanolins produced by the body. 3. The baby will not become sick from the blood. The woman should be warned that he may spit up digested and/or undigested blood after the feeding, however. 4. Topical anesthetics are not used on the breasts. The woman could receive an oral analgesic, however.

81. A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible.

**2. The action is appropriate. The woman should breastfeed frequently. 1. This action is inappropriate. The woman should apply warm soaks to the breast.

47. The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication? 1. Inhibit the mother's active immune response. 2. Aggressively destroy the Rh antibodies produced by the mother. 3. Prevent fetal cells from migrating throughout the mother's circulation. 4. Change the maternal blood type to Rh positive.

** 1. The goal of the injection of RhoGAM is to inhibit the mother's immune response. 2. Immune globulin is composed of anti bodies. When a client receives RhoGAM, she receives passive antibodies to inhibit her immune response. 3. Passive antibodies cannot prevent the migration of fetal cells throughout the mother's bloodstream. 4. A client's blood type is determined by her DNA. RhoGAM cannot change a client's DNA.

36. The nurse is circulating on a cesarean delivery of a G5P4004. All of the client's previous children were delivered via cesarean section. The physician declares after delivering the placenta that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2000 mL. 2. Blood pressure of 160/110. 3. Jaundice skin color. 4. Shortened prothrombin time.

*** 1. The client with a placenta accreta is high risk for a large blood loss. 2. Placenta accreta is not related to a hypertensive state. 3. Placenta accreta is not related to the development of jaundice. 4. The nurse would not expect to detect a shortened prothrombin time when a client has a placenta accreta.

60. Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order? 1. Postpartum clients are high risk for thrombus formation. 2. Post-cesarean clients are high risk for fluid volume deficit. 3. Postpartum clients are high risk for varicose vein development. 4. Post-cesarean clients are high risk for poor milk ejection reflex.

*** 1. This rationale is correct. Because of an elevation in clotting factors, all postpartum clients are at high risk for thrombus formation. 2. The positive pressure boots improve blood return to the heart by preventing pooling of blood in the extremities. They are not applied to treat hypovolemia. 3. The rationale for the use of positive pressure boots is not related to varicose vein development. Varicose veins would, however, increase a client's potential for developing deep vein thrombosis. 4. The rationale for the use of positive pressure boots has nothing to do with a client's milk ejection reflex.

57. A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6ºF, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority? 1. Ineffective breastfeeding. 2. Infection. 3. Ineffective individual coping. 4. Pain.

****2. Infection is the priority nursing diagnosis. A temperature of 104.6ºF, as well as the client's other signs/symptoms, should immediately suggest the presence of infection. The infection is the only one of the four diagnoses that is related to the acute problem. Once the abscess is drained and the antibiotics have been administered, the other three diagnoses will eventually resolve.

49. A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action? 1. Postpartum hemorrhage. 2. Severe postural headache. 3. Pruritic skin rash. 4. Paralytic ileus.

****2. The nurse would expect the client to complain of a severe postural headache. 1. This client in high-Fowler's position is no more at high risk for postpartum hemorrhage than a spinal anesthesia client who has been kept flat after surgery. 3. This client is no more at high risk for a pruritic rash than a spinal anesthesia client who has been kept flat after surgery. 4. This client is no more at high risk for paralytic ileus than a spinal anesthesia client who has been kept flat after surgery.

55. A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority? 1. Lochia is serosa. 2. Client cries throughout the visit. 3. Nipples are cracked. 4. Client yells at the baby for crying.

****4. The client is exhibiting inappropriate behavior when she yells at the baby for crying. The nurse must make additional assessments to determine whether there is any other evidence of abuse or neglect. 1. Lochia serosa at 2 weeks' postpartum is unusual, but it does not put the client or her baby in imminent danger. 2. This client is exhibiting signs of postpartum depression. This is a problem that must be remedied, but it does not put the client or her baby in imminent danger. 3. The client's cracked nipples do need intervention, but they do not put the client or her baby in imminent danger.

64. A postoperative cesarean client, who was diagnosed with severe preeclampsia in labor and delivery, is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question? 1. Methergine (methylergonovine). 2. Magnesium sulfate. 3. Advil (ibuprofen). 4. Morphine sulfate.

***1. Methergine is contraindicated for this client. Methergine is an oxytocic agent. It acts directly on the myofibrils of the uterus. Secondarily it also contracts the muscles of the vascular tree. As a result, client's BP tends to elevate when they receive this medication. This medication should not be given to a client whose BP is 130/90 or higher. 2. Magnesium sulfate is the drug of choice for the treatment of severe preeclampsia. 3. Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID). It is an appropriate medication for the treatment of postpartum cramping. It is not contraindicated for this client. 4. Morphine sulfate is a narcotic analgesic. It is an appropriate medication for the treatment of postsurgical pain. It is not contraindicated for this client.

61. A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following PRN medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Demerol (meperidine). 3. Seconal (secobarbital). 4. Benadryl (diphenhydramine).

***1. Reglan is an antiemetic. It is the drug of choice for a client who is vomiting after surgery. 2. Demerol is a narcotic analgesic. It is not the appropriate medication for this client. 3. Seconal is a sedative. It is not the appropriate medication for this client. 4. Benadryl is an antihistamine. It is not the appropriate medication for this client.

85. A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

***1. Serial grip strengths can be performed to monitor a client for magnesium sulfate toxicity. The only accurate way to assess for toxicity is to check magnesium serum level. Normal level is 1.8-3 mg/dL. Therapeutic is 4-8 mg/dL. Hourly grip strengths along with reflex assessments are excellent noninvasive assessments to monitor for neuromuscular blockage. 2. Kernig's assessment is performed when checking for nuchal rigidity in a client with meningitis. 3. Pupillary responses are performed when a client has had a head injury or is not responsive. 4. Apical heart rate checks are performed when a client has a cardiac disease or is receiving digoxin.

70. A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following laboratory values indicates that the medication is effective? 1. PT (prothrombin time): 12 sec (normal is 10-13 seconds). 2. INR (international normalized ratio): 2.5 (normal is 1.0-1.4). 3. Hematocrit 55%. 4. Hemoglobin 10 g/dL.

***2. The INR should be between 2 and 3. If the PT is more than 2 times normal or the INR is over 3, the client is at high risk for hemorrhage. 1. The PT is normal. For someone taking warfarin, the PT time should be prolonged 1.5 to 2.0 times normal. 3. The hematocrit is elevated. It should be within normal limits.

43. A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication? 1. Chamomile tea can potentiate the affect of the drug. 2. Therapeutic effect may be delayed a week or more. 3. The medication should only be taken whole. 4. A weight gain of up to ten pounds is commonly seen.

***2. The therapeutic effect of selective serotonin receptor inhibitors (SSRIs) like Zoloft is delayed about 1 to 2 weeks from the time the medication is initiated. 1. Chamomile tea has not been shown to potentiate the affect of the medication, but St. John's wort has. 3. This response is incorrect, the medication can be crushed. 4. A 10 pound weight gain is not associated with this medication.

74. A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following should be included in the patient teaching? 1. Only take ibuprofen for pain. 2. Avoid eating dark green leafy vegetables. 3. Drink grapefruit juice daily. 4. Report any decrease in urinary output.

***2. This action is correct. Dark green leafy vegetables contain vitamin K. The vitamin would decrease the anticoagulant affect of Coumadin. 1. Ibuprofen is an NSAID. It can exacerbate the action of Coumadin. The client should be encouraged to take acetaminophen, if needed, for pain. 3. The client should be advised to avoid drinking grapefruit juice. It may increase the action of Coumadin. 4. The client should be advised to report signs of internal bleeding, such as hematuria. Decreased urinary output would not be expected in a client taking Coumadin.

62. A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period? 1. Infection. 2. Bloody urine. 3. Heavy lochia. 4. Rectal abrasions.

***3. The client should be monitored carefully for heavy lochia. 1. The nurse should monitor the client for signs of infection after the first 24 hours have past. 2. The client is not at high risk for bloody urine. 4. The client is not at high risk for rectal

38. A client is 1-day post-cesarean delivery for eclampsia. The client is receiving 5% dextrose in 1⁄2 normal saline IV at 125 cc/hr and magnesium sulfate IV via infusion pump. Which of the following laboratory values should the nurse report to the surgeon? 1. Serum magnesium 7 mg/dL. 2. Serum sodium 136 mg/dL. 3. Serum potassium 3.0 mg/dL. 4. Serum calcium 9 mg/dL.

***3. The serum potassium is below normal. The nurse should report the finding to the physician. 1. A magnesium level of 7 mg/dL is therapeutic. This is an expected level. 2. The serum sodium level is normal. 4. The serum calcium is normal.

67. The nurse is caring for a client, G3P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make? 1. "Thank goodness. It could have been untreatable." 2. "I'm so happy that you have other children who are healthy." 3. "These things happen. They are the will of God." 4. "It is appropriate for you to cry at a time like this."

***4. "It is appropriate for you to cry at a time like this."This statement is appropriate. Clients may need help or permission to express their grief. 1. This statement is inappropriate. Any defect is devastating for the parents to accept. 2. This statement is inappropriate. This child is affected. That is all that matters. 3. This statement is inappropriate. The nurse must not impose his or her beliefs on the couple.

83. A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby's and mother's infection? 1. Staphylococcus aureus. 2. Streptococcus pneumonia. 3. Escherichia coli. 4. Candida albicans.

***4. The baby and mother are infected with Candida albicans. It is critical that they be treated simultaneously for a minimum of 2 weeks. 1. Staphylococcus aureus is the most common bacteria to cause mastitis. 2. Streptococcus pneumonia is a major cause of pneumonia. 3. Escherichia coli cause severe gastritis.

80. A nurse is assessing a 1 day-postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10 point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic.

**1. The client should be assessed by her health care practitioner. The client is complaining of an excessive amount of pain after having received a relatively large dose of ibuprofen. Because the perineum is edematous, the lochial flow normal, and the pain level is well above the expected, the nurse should suspect a hematoma. The client should be assessed by her HCP.

65. A nurse administered RhoGAM to a client whose blood type is A (positive). Which of the following responses would the nurse expect to see? 1. Fever, flank pain, elevated bilirubin. 2. Induration and redness at the injection site. 3. Mild pain and swelling at the injection site. 4. Polycythemia, headache, hives.

**1. The nurse would expect to see fever, flank pain, dark-colored urine, and elevated bilirubin levels. When a client is Rh positive, antibodies against the client's red blood cells are being injected into her body. A hemolytic response similar to one seen when a client receives the wrong type of blood may develop. 2. If the client were Rh (negative), the nurse would expect to see induration and redness at the injection site. 3. If the client were Rh (negative), the nurse would expect to see mild pain and swelling at the injection site. 4. The nurse would expect to see a hemolytic response, not polycythemia.

75. A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman? CHAPTER 11 HIGH-RISK POSTPARTUM 425 1. Endometrial ischemia. 2. Postpartum hemorrhage. 3. Prolapsed uterus. 4. Vaginal hematoma.

**2. The nurse should carefully monitor this client for signs of postpartum hemorrhage

66. A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time? 1. Tell the father that his behavior is inappropriate. 2. Sit with the family and quietly communicate sorrow at their loss. 3. Help the couple to understand that their daughter is acting inappropriately. 4. Encourage the couple to send their daughter to her grandparents.

**2. This action is appropriate. The nurse is acknowledging that every member of the family is grieving the loss. 1. This father is grieving. His anger is appropriate at this time. 3. Five-year-old children do not understand death. They do respond to their parents' unusual behaviors. 4. Even though it is very difficult for the parents to deal with their own grief while caring for their daughter, the young girl may feel abandoned if sent unexpectedly to her grandparents.

77. A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis.

1. This client is high risk for uterine atony. The uterus of a woman who delivers a macrosomic baby has been stretched beyond the usual pregnancy size. The muscle fibers of the myometrium, therefore, are stretched. After delivery the muscles are often unable to contract effectively to stop the bleeding at the placental separation site.

34. A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O (negative), the baby's type is A (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate? 1. Advise the client to keep her physician appointment at the end of the week in order to receive her RhoGAM injection. 2. Make sure that the client receives a RhoGAM injection before she is discharged from the hospital. 3. Notify the client that because her baby's Coombs' test was negative she will not receive an injection of RhoGAM. 4. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.

1. This response is incorrect. RhoGAM must be administered within 72 hours of delivery. ***2. This response is correct. The nurse should not finalize an Rh (negative) client's discharge until the client has received her RhoGAM injection. 3. This response is incorrect. A negative direct Coombs' test means that no maternal antibodies were detected in the baby's circulatory system. The nurse would expect to detect a negative direct Coombs' test. 4. This response is unacceptable. Rh-(negative) clients should receive their RhoGAM injection before 72 hours' postpartum or by discharge, whichever is earlier.

69. A client who has been diagnosed with deep vein thrombosis has been ordered to receive 12 units heparin/min. The nurse receives a 500-mL bag of D5W with 20,000 units of heparin added from the pharmacy. At what rate in mL/hr should the nurse set the infusion pump? __________mL/hr.

18 mL/hour

54. A client is 3-days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective? 1. The client has had no seizures since delivery. 2. The client's blood pressure has dropped from 160/120 to 130/90. 3. The client's postoperative weight has dropped from 154 to 144 lb. 4. The client states that her headache is gone.

2. Hydralazine is an antihypertensive. The change in blood pressure indicates that the medication is effective.

15. A woman, who wishes to breastfeed, advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate? 1. Advise the woman that unfortunately she will be unable to breastfeed. 2. Examine the woman's breasts to see where the incision was placed. 3. Monitor the baby's daily weights for excessive weight loss. 4. Inform the woman that reduction surgery rarely affects milk transfer

3. Monitor the baby's daily weights for excessive weight loss. This action is very important. During breast reduction surgery, fat tissue is removed from the breast. Because the breast is much smaller, the nipple must be moved to a new location. During these procedures, the client's mammary ducts may be ligated. If the ducts are severed, the woman will not be able to transfer the milk produced in her glandular tissue to the baby.

16. The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? 1. Ineffective lactogenesis. 2. Dysfunctional parenting. 3. Wound dehiscence. 4. Projectile vomiting.

3. This client is at high risk for wound dehiscence. Her wound healing may be impaired because of her diabetes and because of her obesity.

4. A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is, "Bleeding and saturating a pad about every 1⁄2 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bed rest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please come in whenever you are ready."

4. "The physician should see you. Please come in whenever you are ready." This is the correct response. This client needs to be evaluated.

10. The nurse should suspect puerperal infection when a client exhibits which of the following? 1. Temperature of 100.2ºF. 2. White blood cell count of 14,500 cells/mm3. 3. Diaphoresis during the night. 4. Malodorous lochial discharge.

4. A malodorous lochial flow is a common sign of a puerperal infection. "Puerperium" is another word for "postpartum." Although a client may have a slight temperature elevation, an elevated WBC count and/or be diaphoretic, all three symptoms are normally seen in the postpartum client. The only finding that will make a nurse suspect infection is the malordorus lochial flow. The other findings are WNL for a postpartum woman.

35. The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby with visible defects. Which of the following actions by the nurse is appropriate? 1. Discourage the parents from naming the baby. 2. Advise the parents that the baby's defects would be too upsetting for them to see. 3. Transport the baby to the morgue as soon as possible. 4. Give the parents a lock of the baby's hair and a copy of the footprint sheet.

4. Give the parents a lock of the baby's hair and a copy of the footprint sheet. This is appropriate. The small mementos will provide the couple with something tangible to remember the pregnancy and baby by. 1. This is inappropriate. Naming the baby is a means of acknowledging both the existence and the death of the baby. 2. This is inappropriate. Client's imaginations of what the baby looks like are often much worse than the reality. 3. This is inappropriate. The couple should be provided time to be with their baby before transporting the baby to the morgue.

82. A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 1. Breast implants often contaminate the milk with toxins. 2. The glandular tissue of women who need implants is often deficient. 3. Babies often have difficulty latching to the nipples of women with breast implants. 4. Women who have implants are often able exclusively to breastfeed.

4. This information is true. Women who have had augmentation surgery usually are able to breastfeed exclusively.

46. A client just delivered the placenta pictured below. The nurse will document that the woman delivered which of following placentas? 1. Circumvallate placenta. 2. Succenturiate placenta. 3. Placenta with velamentous insertion. 4. Battledore placenta.

46. 1. A circumvallate placenta is a placenta with an inner ring created by a fold in the chorion and amnion. Clients with this type of placenta are at high risk for antepartal complications like preterm labor. 2. A succenturiate placenta is characterized by one primary placenta that is attached via blood vessels to satellite lobe(s). Clients with this type of placenta are at high risk for postpartum hemorrhage. 3. A placenta with a vellamentous insertion has an umbilical cord that is formed a distance from the placenta. Since the vessels are unsupported between the placenta and the cord, hemorrhage may result if one or more of the vessels tears. /////4. The battledore placenta is characterized by an umbilical cord that is inserted on the periphery of the placenta. Clients with this type of placenta are at high risk for preterm problems like preterm labor and hemorrhage.

73. A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take? Select all that apply. 1. Swaddle the baby in a baby blanket. 2. Discuss funeral options for the baby. 3. Encourage the couple to try to get pregnant again soon. 4. Ask the couple whether or not they would like to hold the baby. 5. Advise the couple that the baby's death was probably for the best.

73. 1, 2, and 4 are correct. 1. This is an appropriate action. The baby should be handled with respect. 2. This is an appropriate action. Funerals help clients to achieve closure and to provide others with a means of acknowledging the baby's death. 4. This is an appropriate action. Although there are some clients who will decline to hold their babies, the action is very important for those who accept the opportunity.

84. A client on the postpartum unit has been diagnosed with deep vein thrombosis. The following titration schedule is included in the client's orders: If INR is 1: administer 7500 units heparin subcutaneously (sc) If INR is 1.1 to 2: administer 5000 units heparin sc If INR is 2.1 to 3: administer 2500 units heparin sc If INR is 3: administer 0 units heparin sc The client's INR is 2.6. How many mL of heparin will the nurse administer if the available concentration of heparin is 5000 units per 0.2 mL? __________ mL.

84. 0.1 mL