Questions: Maternity Postpartum OB Test #2

A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list?

* Wear a supportive bra. * Rest during the acute phase. * Maintain a fluid intake of at least 3000mL. * Continue to breast-feed if the breasts are not too sore.

A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 & 4. In planning for admission of this newborn, the nurse's highest priority should be to:

Connect the resuscitation bag to the oxygen outlet.

A nurse is assessing a newborn infant after circumcision & notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions is appropriate?

Document the findings.

A nurse in a delivery room is assisting with the delivery of a newborn. After delivery, the nurse prepares to prevent heat loss in the newborn resulting fro evaporation by:

Drying the infant with a warm blanket.

A nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness & dizziness. Which nursing action would be most appropriate?

Instruct the client to request help when getting out of bed.

A nurse is preparing to administer beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which of the following routes?

Intratracheal. Respiratory distress is common in a premature neonates and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route.

A nurse is assessing a client in the fourth stage of labor & notes that the fundus is firm, but that bleeding is excessive. Which of the following would be the initial nursing action?

Notify the physician.

A nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which of the following, if stated by the client, would indicate a need for further instructions?

"I should wash my nipples daily with soap & water."

The nurse determines that a new mother understands the teaching about prevention of newborn abduction is she states:

"I will ask the nurse to attend to my infant if I am napping & my husband is not here."

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. The instructor determines that the student needs to research this procedure further if the student states that:

"I will flush the eyes after instilling the ointment."

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate?

* Monitor skin temperature closely. * Reposition the newborn every 2 hours. * Cover the newborn's eyes with eye shields or patches.

A nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which of the following assessment findings would best indicate the presence of hematoma?

Changes in vital signs.

A postpartum client is diagnosed with cystitis. The nurse plans for which priority nursing intervention in the care of the client?

Encouraging fluid intake.

A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum & notes that the client has saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as:

Heavy

A nurse develops a plan of care for a woman with HIV infection & her newborn. The nurse includes which intervention in the plan of care?

Maintaining standard precautions at all times while caring for the newborn.

A nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?

Monitor he newborn's response to feedings & weight gain pattern.

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots & notes that they are larger than 1 cm. Which nursing action is appropriate?

Notify the physician. *(Clots that are larger than 1 cm, are big!)

A nurse is planning care for a newborn of a diabetic mother. A priority nursing diagnosis for this infant is:

Risk for Injury related to low blood glucose levels.

A nurse has provided discharge instructions to a client who delivered a healthy infant by cesarean delivery. Which statement made by the client indicates a need for further instructinos?

"I will begin abdominal exercises immediately."

A nurse prepares to administer a vitamin K injection to a newborn, & the mother asks the nurse why her infant needs the injection. The best response by the nurse would be:

"Newborns are deficient in vitamin K, & the injection prevents your newborn from bleeding."

A nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which of the following sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats/min.

A postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs & symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins.

A nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which of the following statements?

* "I should wear a bra that provides support." * "Drinking alcohol can affect my milk supply." * "The use of caffeine can decrease my milk supply." * "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

A postpartum nurse is providing instructions to a client after delivery of a healthy infant. The nurse instructs the client that she should expect normal bowel elimination to return.

3 days postpartum

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care & prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage.

A nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn?

Incessant crying.

A nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage?

A multiparous client who delivered a large fetus after oxytocin (Pitocin) induction.

A nurse notes hypotonia, irritability, & a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome & is aware that which additional sign would be consistent with fetal alcohol syndrome.

Abnormal palmar creases.

A nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a mid-line episiotomy & has several hemorrhoids. What is the primary nursing diagnosis for this client?

Acute pain

A client in a postpartum unit complains of sudden sharp chest pain & dyspnea. The nurse notes that the client is tachycardic & the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which of the following would be the initial nursing action?

Administer oxygen, 8 to 10 L/min, by face mask.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?

Ask the client to urinate & empty her bladder.

A postpartum nurse is taking the vital signs of a client who delivered a healthy infant 4 hours ago. The nurse notes that the client's temperature is 100.2 F. Which of the following actions would be appropriate?

Increase hydration by encouraging oral fluids. ***(Dehydration could be the cause)

Rho(D) immune globulin (RhoGAM) is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following?

Being affected by Rh incompatibility.

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, the priority nursing assessment is to check the:

Blood pressure. Methylergonovine, an ergot alkaloid, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate blood pressure. A priority assessment before the administration of the medication is to check the blood pressure.

The mother of a newborn calls a clinic & reports to a nurse that when cleaning the umbilical cord, the mother noticed that the cord was moist & that discharge was present. The appropriate nursing instruction to the mother is which of the following?

Bring the infant to the clinic. *(symptoms indicate infection)

A postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse provides which appropriate instruction to he mother?

Continue to breast-feed every 2 to 4 hours.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft & boggy. Which nursing intervention would be appropriate initially?

Massage the fundus until it's firm.

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which condition is documented in the client's medical history?

Peripheral vascular disease *(can cause a blood clot)

A nurse is developing a plan of care for a pospartum client with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours after delivery?

Prepare an ice pack for application to the area.

A nurse administers erythromycin ointment (0.5%) to the eyes of a newborn & the mother asks the nurse why this is performed. The nurse explains to the mother that this is routinely done to:

Prevent opthalmia neonatum from occurring after delivery in a newborn with an untreated gonococcal infections.

After a preciptious delivery (fast labor <3hrs), a nurse notes that the new mother is passive & only touches her newborn infant briefly with her fingertips. The nurse should do which of the following to help the woman process what has happened?

Support the mother in her reaction to the newborn infant.

A nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment signs noted in the newborn would alert the nurse to the possibility of this syndrome?

Tachypnea & retractions

A nurse is caring for four 1-day postpartum clients. Which client has an abnormal finding that would require further intervention?

The client with lochia that is red & has a foul-smelling odor.

A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the nurse include?

The diet should include additional fluids.