Chapter 26 - Postpartum Complication Practice Questions

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? A. Changes in Vital signs B. Signs of heavy flushing C. Complains of intense pain D. Complains of a tearing sensation

A rationale: epidural anesthesia = she cannot feel pain, pressure or tearing sensation - changes in VS indicate hypovolemia in anesthetized clients

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instruction should be included on the list? A. wear a supportive bra B. Rest during the acute phase C. Maintain a fluid intake of at least 3,000 mL/day D. Continue to breastfeed if the breast are not too sore E. Take the prescribed antibiotics until the soreness subsides F. Avoid decompression of the breasts by breastfeeding or breast pump

A B C D

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? A. providing sitz bath B. encouraging fluid intake C. placing ice on the perineum D. Monitoring hemoglobin and hematocrit levels

B rationale: client shoudl increase fluid intake to at least 3,000 mL/day if not contraindicated

The nurse is monitoring a client in the immediate post-partum period for signs of hemorrhage. Which sign if noted, would be an early sign of excessive blood loss? A. A temperature of 100.4F B. An increase in the pulse rate from 88 to 102 bpm C. A blood pressure change from 130/88 to 124/80 D. An increase in respiratory rate from 18 to 22 breaths per minute

B rationale: during 4th stage of labor (RR, BP, pulse should be checked every 15 minutes during first hour)

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? A. A primiparous client who delivered 4 hours ago B. A multiparous client who delivered 6 hours ago C. A multiparous client who delivered a large baby after oxytocin induction D. A primiparous client who delivered 6 hour ago and had epidural anesthesia

C rationale: Causes of PP hemorrhage = laceration, uterine atony, hematoma, retained placental fragments

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? A. Document the findings B. Elevate the client's legs C. Massage the fundus until firm D. Push on the uterus to assist in expressing clots

C rationale: if uterus not firm - first intervention is always to massage until it is firm

The postpartum nurse is assessing a client who delivered a health infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? A. Paleness of the calf area B. Coolness of the calf area C. Enlarged, hardened veins D. Palpable dorsalis pedis pulses

C rationale: superficial - S&S = swelling, tenderness, inflammation, warmth - can palpate enlarged hard veins - clients can experience pain with ambulation

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excess. Which should be the initial nursing action? A. Record the findings B. Massage the fundus C. Notify the obstetrician D. place the client in Trendelenburg's position

C rationale: hard fundus with excessive bleeding could be laceration - massaging fundus wouldn't be effective - Trendelenburg's would interfere with cardiac and respiratory function - avoid

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? A. Initiate an IV line B. assess the client's blood pressure C. Prepare to administer morphine sulfate D. Administer oxygen 8-10L/minute by mask

D Rationale: - to decrease hypoxia - bed rest with elevated head to reduce dyspnea - other options are not done first

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse would include which specific action during the first 12 hours after delivery? A. encourage ambulation hourly B. assess vital signs every 4 hours C. measure fundal height every4 hours D. prepare and ice pack for application to the area

D rationale: to reduce swelling caused by hematoma formation other interventions are not specific to hematoma care hourly ambulation increases risk for bleeding client assessment every 4 hours is too frequent

The nurse is providing instruction about measures to prevent postpartum mastitis to a client who is breastfeeding her newborn. Which client statement would indicate a need for further instruction? A. I should breastfeed every 2-3 hours B. I should change the breast pads frequently C. I should wash my hands well before breastfeeding D. I should wash my nipples daily with soap and water

D rationale: washing with soap and water could cause dry and crackling skin --> allows for entry of pathogens to cause mastitis