NCLEX 3000 Maternal-Postpartum
A 24-year-old multigravida client who had an uncomplicated, spontaneous vaginal delivery 7 hours ago is uninterested in her baby and wants to sleep. The student nurse assigned to care for the client is concerned and tells the licensed practical nurse (LPN) who's also assigned to her care. Which response by the LPN is most effective in educating the student nurse?
"Extreme fatigue from the delivery is common, and new mothers initially focus on recovery and taking in the birth experience."
The nurse demonstrates bathing of a neonate to a primiparous client. Which statement by the client indicates understanding?
"I'm going to bathe the baby in the kitchen because it's nice and warm there."
The nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching?
"If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."
A postpartum client who is bottle-feeding her neonate asks the nurse when she can expect her menstrual period to return. How should the nurse respond?
"In 7 to 9 weeks"
On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which response by the nurse would be appropriate?
"It isn't unusual to have those feelings after delivery."
A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician prescribes bethanechol (Urecholine), 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond?
"It stimulates the smooth muscle of the bladder."
A new mother who's breast-feeding asks how quickly she can expect to lose the 40 lb she gained during pregnancy. Which response by the nurse is best?
"It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended."
After delivering her second baby, the client tells the nurse that she wants to breast-feed this baby. She indicates that she was unsuccessful at breast-feeding her first child and that she bottle-fed after 3 days of trying to nurse. Which of the following responses would best support this client's breast-feeding efforts?
"It's important to room-in with your newborn so that you can respond to her nursing cues."
The nurse is teaching a client how to use a diaphragm. Which instruction should the nurse provide?
"Leave the diaphragm in place for at least 6 hours after intercourse."
The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What is the best response by the nurse?
"You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."
(SELECT ALL THAT APPLY) The nurse is collecting data on client who is 1 day postpartum. The nurse expects which normal findings?
(1) Lochia Rubra, (4) Heart rate of 50 to 70 beats/minute
(SELECT ALL THAT APPLY) The nurse observes several interactions between a mother and her new son. Which of the following behaviors by the mother would the nurse identify as evidence of mother-neonate attachment?
(1) Talks and coos to her son, (2) Cuddles her son close to her
(SELECT ALL THAT APPLY) On examining a client who gave birth 3 hours ago, the nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which of the following actions should the nurse take?
(2) Assess the client's vital signs., (3) Palpate the client's fundus.
The physician prescribes phytonadione (AquaMEPHYTON), 0.5 mg I.M., for a neonate born 30 minutes ago. The nurse has a solution containing 2 mg/ml. How many milliliters of solution should the nurse administer to achieve this dose?
0.25
A client has just begun taking an oral contraceptive that contains estrogen and progestin. The nurse should explain that full contraceptive benefits won't occur until the client has taken the drug for at least:
10 days.
The nurse determines that a postpartum client's perineal pad weighs 100 g. The nurse should document this client's blood loss as:
100 ml
After receiving methylergonovine (Methergine) I.M. for postpartum hemorrhage, a client is prescribed methylergonovine 0.4 mg by mouth every 6 hours. The pharmacy sends 0.2 mg tablets. How many tablets must the nurse administer with each dose?
2
A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by:
3 days of elevated basal body temperature and clear, thin cervical mucus.
The uterus returns to the pelvic cavity in which of the following time frames?
7 to 9 days postpartum
Which client care assignment is the most appropriate assignment for a newly graduated licensed practical nurse (LPN)?
A 24-year-old primigravida who delivered a 6-lb, 4-oz (2,835-g) baby vaginally 4 hours ago and is unable to void
At her follow-up examination, a client who's 6 weeks postpartum tells the nurse that she's exhausted and sore from breast-feeding and wants to formula-feed her baby. She also mentions that she feels like a failure and finds it increasingly difficult "just to get out of bed in the morning." Which intervention should the nurse attempt before notifying the physician?
Acknowledging the client's feelings, asking about other life stressors, and identifying the client's support system
A postpartum client tells the nurse she isn't having regular bowel movements. The nurse should recommend that the client do what to combat constipation?
Add high-fiber foods to her diet.
One day after having a cesarean birth, a client complains of incisional pain that she rates as a 3 on a 1-to-10 scale, with 10 representing the most severe pain. The physician prescribed ibuprofen (Motrin), 400 mg by mouth every 4 to 6 hours, as needed. Which intervention should the nurse take when administering this drug?
Administer the drug with meals or milk.
The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rho(D)-negative and her baby is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?
Administration of Rho(D) immune globulin I.M. to the mother within 72 hours
A breast-feeding client is diagnosed with mastitis. Which nursing intervention would be most helpful to her?
Advising her to massage the affected area gently while breast-feeding
The nurse brings a new mother her baby for the first time approximately 1 hour after the baby's birth. After checking the identification, the nurse hands the baby to the mother. Within a few minutes, the mother begins to undress her baby. Which of the following should the nurse do?
Anticipate and support the behavior as a normal part of bonding.
A client who delivered by cesarean birth 3 days ago is bottle-feeding her neonate. While the nurse collects data, the client complains that her breasts are painful, hard, and warm to the touch. How should the nurse intervene?
Apply an elastic bandage to bind the breasts.
The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?
Apply an ice pack to her perineum.
The nurse is planning to discharge a 24-year-old gravida 1, para 1, non-English-speaking Hispanic client. The client's English-speaking cousin is acting as a translator for the nurse and client. Which nursing intervention takes priority?
Arranging for a home care nurse to assess the client in her home environment
The nurse is caring for a client who just delivered triplets. Which intervention by the nurse is most important?
Assessing fundal tone and lochia flow
The nurse understands that measures are necessary to contain health care costs. Which intervention demonstrates effective resource management?
Assigning the nurse's aide to deliver meal trays and to stock rooms; assigning the licensed practical nurse to collect assessment data
A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary health care provider?
Blurred vision and headache
A client is resting comfortably 4 hours after delivering her first child. When measuring her heart rate, the nurse expects which normal finding?
Bradycardia
After receiving the shift report, the nurse realizes that she should monitor her postpartum client closely for puerperal infection. Which factor alerted the nurse to the client's risk for this complication?
Cesarean birth
A clinical pathway is guiding care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The client has no episiotomy and is bottle-feeding her baby. Which outcome should be achieved within the next 8 hours?
Client will demonstrate ability to bottle-feed the neonate.
Certain drugs used during the postpartum period may affect blood pressure. Which drug would decrease a postpartum client's blood pressure?
Codeine phosphate
What is the most likely reason for a temperature of 99.8° F (37.7° C) during the first 24 hours postpartum?
Dehydration
A client delivers a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's husband seems withdrawn and barely speaks to the staff when visiting his child in the NICU. His behavior indicates that he's in which stage of grief?
Depression
A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this client, which strategy by the nurse would be most helpful?
Encourage the client to see, touch, and hold the dead neonate.
When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is appropriate?
Encouraging increased fluid intake
A 28-year-old woman gave birth 1 hour ago to a full-term baby boy. Which finding should the nurse expect when palpating the client's fundus?
Firm, at the level of the umbilicus
The nurse is preparing to perform a physical examination on a postpartum client. Which statement best explains why the nurse must wear gloves during this examination?
Gloves are required for standard precautions.
(SELECT ALL THAT APPLY) A client is at risk for which postpartum complication during the fourth stage of labor?
Hemorrhage
In the fourth stage of labor, a full bladder increases the risk of which postpartum complication?
Hemorrhage
A client is receiving oxytocin (Pitocin) to treat postpartum hemorrhage. When planning the client's care, the nurse anticipates monitoring for which common adverse reactions?
Hypertension and tachycardia
Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following steps would be contraindicated when caring for this client?
Instructing the client to use two or more peripads to cushion the area
The nurse explains to new parents the importance of maintaining their infant's safety during hospitalization. Which action best ensures the infant's safety?
Instructing the mother to notify staff when she showers to avoid leaving the infant unattended
During an annual checkup, a client tells the nurse that she and her husband have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?
It should begin before conception and end 3 months after delivery.
Which of the following options best describes the anticipated actions in the taking-hold phase of the maternal attachment process?
Kissing, embracing, and caring for the infant
As a postpartum client adapts to her maternal role, she progresses through several phases. During which phase does she begin to accept the neonate as a separate individual?
Letting-go phase
On her 3rd postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What do these findings suggest?
Localized infection
On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority?
Massaging the uterus gently
When caring for a client who has had a cesarean section, which of the following actions is appropriate?
Monitoring pain status and providing necessary relief
When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take?
Notify the physician.
A licensed practical nurse (LPN) who typically works in the neonatal intensive care unit is being cross-trained to work with postpartum clients. The charge nurse is busy with a delivery and assigns her to stock rooms, which is typically the responsibility of a nurse's aid. As she enters a client's room, the LPN notices that a client looks pale and shaky. Which action should she take?
Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data.
Three hours after birth, a client becomes weak and dizzy as she attempts to ambulate for the first time. The client's hemoglobin level at the end of pregnancy was 10.4 g/dl. Two hours later she asks to use the bathroom. Which nursing intervention is the top priority?
Obtaining the assistance of a second nurse before attempting to assist the client with ambulation
A client is at the end of her 1st postpartum day. When assessing her uterus, the nurse expects to find the top of the fundus at the midline and at which position?
One fingerbreadth below the umbilicus
A client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate?
Performing fundal massage
While preparing a client for a postpartum tubal ligation, the nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse is best?
Privately discussing with the client her understanding of the procedure
A client who is breast-feeding her infant is experiencing breast engorgement. The nurse suggests breast pumping to relieve the breast engorgement. Which instruction should the nurse provide?
Pump each breast for at least 10 minutes every 3 to 4 hours; pump at night only if she's awake.
A postpartum client is ready for discharge. During discharge preparation, the nurse should instruct her to report which of the following to her primary health care provider?
Redness, warmth, and pain in the breasts
A 41-year-old multipara client had a spontaneous vaginal delivery of an 8-lb (3,629-g) baby 3 hours ago. The nurse collects the following data: "Fundus firm, three fingerbreadths above the umbilicus and deviated to the right. Perineal pad saturated after 20 minutes." Which nursing intervention by the licensed practical nurse (LPN) is best?
Reminding the client to void and helping her to the bathroom
A client with a first-degree tear and swollen perineum is 28 hours postpartum when she requests assistance with her first sitz bath. Which intervention by the nurse is necessary at this time?
Requesting that the client call for assistance to walk back to bed when she's finished with the sitz bath
The nurse is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client?
Risk for deficient fluid volume related to hemorrhage
A breast-feeding baby will turn his head toward the mother's breast in a natural instinct to find food. What is the name of this reflex?
Rooting reflex
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
Scant lochia rubra
A multiparous client with pelvic thrombophlebitis is being treated with bed rest and anticoagulant therapy. The nurse should call for assistance immediately if the client experiences which symptom?
Sudden onset of shortness of breath
Which of the following options is the most important aspect of nursing care in the postpartum period?
Supporting the mother's ability to successfully feed and care for her infant
The nurse is assessing the psychosocial status of a postpartum client. Which finding is most likely to promote parent-neonate attachment?
Sustained parent-neonate contact immediately after delivery
A client delivered a healthy full-term baby girl 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action?
Tachycardia and hypotension
Which of the following correctly defines puerperium?
The 6 weeks following birth
Which assessment finding indicates that the infant isn't latching on properly during breast-feeding.
The baby's lips smack.
The nurse is reviewing the history of a postpartum client. Which history factor strongly suggests that this client will experience afterpains?
The client is a gravida 6, para 5.
A client, age 22, is a gravida 1, para 0. During the first 24 hours after delivery, she doesn't show consistent interest in her neonate. How should the nurse interpret her behavior?
The client is showing expected behaviors for the taking-in period.
A clinical pathway is guiding care for an Rh-negative postpartum client who vaginally delivered a 9-lb, 1-oz (4,121-g) baby 5 hours ago. During the delivery, a second-degree median episiotomy was necessary. Which client outcome should be achieved during the first 12 hours postpartum?
The client will verbalize and demonstrate appropriate self-perineal care.
The nurse is discharging a 34-year-old multipara client who, after 16 hours of labor, delivered an 8-lb, 14-oz (4,032-g) baby vaginally. The nurse notes that the mother is rubella-immune with Rh-positive blood. Which client outcome takes priority for this client?
The client will verbalize the importance of reporting changes in lochia flow.
During the postpartum period, the nurse should assess for signs of normal involution. Which of the following would indicate that the client is progressing normally?
The uterus is descending at the rate of one fingerbreadth per day.
Which of the following interventions would be appropriate to include in the plan of care for a client during the fourth stage of labor?
Time with the baby to initiate breast-feeding
The nurse is teaching a postpartum client how to perform Kegel exercises. What is the purpose of these exercises?
To strengthen the perineal muscles
Which finding would lead the nurse to suspect that a client has developed hypovolemic shock caused by postpartum hemorrhage?
Urine output less than 25 ml/hour
A client who is breast-feeding her baby experiences pain, redness, and swelling of her left breast 9 days postpartum. She is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?
Use a warm, moist compress over the painful area.
A client's neonate was delivered by cesarean. Which management strategy should be implemented regarding breast-feeding after this type of delivery?
Use the football hold to avoid incisional discomfort.
The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?
Using a peri bottle to clean the perineum after each voiding or bowel movement
Breast engorgement occurs on the second or third postpartum day. Which of the following processes causes engorgement?
Vasodilation, which causes the breast to feel full
The nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?
Washing the hands and wearing gloves
The nurse visits a client at home on the tenth postpartum day. When assessing the client's uterus, the nurse expects to find:
a nonpalpable fundus in the abdomen.
A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to:
breast-feed every 1½ to 3 hours.
Normal lochial findings during the first 24 hours following delivery include:
bright red blood.
A client asks the nurse about the rhythm (calendar-basal body temperature) method of family planning. The nurse explains that this method involves:
determination of the fertile period to identify safe times for sexual intercourse.
The nurse is teaching a client about oral contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct her to:
discard the pack, use an alternative contraceptive method until her menses begins, and start a new pack on the regular schedule.
Which physiologic response should the nurse expect during the early postpartum period?
diuresis
A client who delivered her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring for the baby." The nurse should:
help the client break down large tasks into smaller ones.
One day after a client gives birth, the nurse performs a postpartum assessment. At this time, the nurse expects to find:
lochia rubra.
After 2 days of breast-feeding, a postpartum client reports nipple soreness. To relieve her discomfort, the nurse should suggest that she:
lubricate her nipples with expressed milk before feedings.
The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be:
red and moderate.
During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his mouth. To resolve this problem, the nurse should suggest that the mother:
stroke the neonate's lips gently with the nipple.
A client says she wants to practice natural family planning. The nurse teaches her how to use the calendar method to determine when she's fertile and advises her to avoid unprotected intercourse. When teaching her how to determine her fertile period, the nurse should instruct her to:
subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle.
A client is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the client's risk of:
tubal or ectopic pregnancy.
A postpartum client decides to bottle-feed her neonate. To prevent breast engorgement, the nurse should recommend that she:
wear a supportive, well-fitting brassiere.
The nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?
"Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."
After a vaginal delivery, a postpartum client complains of perineal discomfort when sitting. To promote comfort, the nurse should provide which instruction?
"Contract your buttocks before sitting or rising."
The night nurse reports that a postpartum client is homeless, has poor hygiene, and has tested positive for the human immunodeficiency virus (HIV). The nurse assigned to care for the client requests that the assignment be changed because she's pregnant and doesn't want to risk exposure. Which response by the charge nurse indicates an understanding of the ethical responsibilities of a professional nurse?
"It's inappropriate to refuse this assignment; all clients should be treated equally."
The nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?
"The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment."
(SELECT ALL THAT APPLY) The nurse is instructing the client on breast-feeding. Which instructions should she include to help the mother prevent mastitis?
(2) Change the breast pads frequently., (3) Expose your nipples to air part of each day., (4) Wash your hands before handling your breast and breast-feeding., (6) Release the baby's grasp on the nipple before removing him from the breast.
(SELECT ALL THAT APPLY) The nurse is assisting in developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis Acute pain related to perineal sutures?
(3) Administer sitz baths three to four times per day., (4) Encourage the client to do Kegel exercises.
When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following descriptions provides an accurate picture of retention with overflow?
A varying urge to urinate with an average output of 100 ml
The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first?
Explore her own personal beliefs and feelings about contraception.
Lochia normally progresses in which of the following patterns?
Rubra, serosa, alba
The nurse is collecting data on a neonate. Which finding indicates that the neonate's fontanels are normal?
They're soft to touch.
As part of the postpartum follow-up, the nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information, which of the following assessments would the nurse make?
This is expected behavior for a client 3 to 7 days postpartum.
While talking to the nurse, the parents of a neonate in the neonatal intensive care unit (NICU) express concern that they're neglecting their 3-year-old son. The nurse suggests a sibling visit. To best promote the sibling's attachment to the neonate, the nurse should:
suggest that the sibling bring in a drawing to display near the neonate's crib in the NICU.
The nurse should tell new mothers who are breast-feeding that breast milk is produced when:
the placenta is delivered, causing the secretion of prolactin.
