270 5-6 (270 exam 3)
A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? "Expect to see your 2-year-old become more independent when the baby gets home." "Talk to your 2-year-old about the baby when you're driving him to day care." "Have your 2-year-old stay at home while you're here in the hospital." "Ask your 2-year-old to pick out a special toy for his sister."
"Ask your 2-year-old to pick out a special toy for his sister."
A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? "It might take up to a week for your bowels to return to their normal pattern." "I'll get a laxative prescribed so that you can move your bowels." "That's unusual. Are you making sure to eat enough?" "Let me call your health care provider about this problem."
"It might take up to a week for your bowels to return to their normal pattern."
An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification? "The client reports a pain level of 8. She has a low pain tolerance." "I changed the client position from her back to her side." "The client is experiencing lower back pain and I gave a backrub." "I instructed the client to ring if she felt the need to move her bowels."
"The client reports a pain level of 8. She has a low pain tolerance."
A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? "Call your health care provider if you saturate a peri-pad in less than 4 hours." "You should be seen by your health care provider if you have blurred vision." "Follow up with your health care provider within 3 weeks of being discharged." Notify the health care provider if your temperature is greater than 99° F (37.2° C)."
"You should be seen by your health care provider if you have blurred vision."
The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? 4 weeks 1 week 3 weeks 2 weeks
2 weeks
The nursing instructor is conducting a class discussion on the various agents used during labor and delivery to assist the client. The instructor determines the class is successful after the students correctly choose which factor as true about the use of systemic analgesia?
Benzodiazepines enhance pain relief attained with opioids and cause sedation.
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate? Obtain a urine culture; the woman most likely has a urinary tract infection. Notify the health care provider about this elevation; this finding reflects infection. Inspect the perineum for hematoma formation. Continue to monitor the woman's temperature every 4 hours; this finding is normal.
Continue to monitor the woman's temperature every 4 hours; this finding is normal.
A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? Determine if the client is emptying her bladder. Perform an "in and out" catheter on the client. Ask the client when she last urinated. Educate the client on how to perform Kegel exercises.
Educate the client on how to perform Kegel exercises.
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. Give newborns water and other foods to balance nutritional needs. Help the mother initiate breastfeeding within 30 minutes of birth. Provide breastfeeding newborns with pacifiers. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.
Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.
The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist? Dry, cracked lips Inability to push Urinary retention Rapid progress of labor
Inability to push
Which nursing instruction is best when helping the woman deliver the fetus in a controlled manner? Instruct the client to change positions frequently. Instruct the client to limit fluid intake until after the second stage of labor. Instruct the client to bare down and push with each contraction. Instruct the client to blow through the lips like blowing out candles.
Instruct the client to blow through the lips like blowing out candles.
A nurse is assessing a postpartum client. Which measure is appropriate? Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. Perform the examination as quickly as possible. Wear sterile gloves when assessing the pad and perineum. Instruct the client to empty her bladder before the examination.
Instruct the client to empty her bladder before the examination.
A client has had a normal labor progression after the spontaneous rupture of clear fluid at home. As the client continues to show no signs of complications, which actions should the nurse prioritize to prepare for the birth? Select all that apply. Open the newborn crash cart or box to ensure easy access to all supplies. Move the newborn warmer to the birth area and turn it on. Check the functionality of the oxygen source and equipment. Document events as they are happening. Connect the meconium aspirator to the wall suction and turn it on.
Move the newborn warmer to the birth area and turn it on. Check the functionality of the oxygen source and equipment. Document events as they are happening.
A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? Palpate the mother's radial pulse at the same time. Ask the woman to hold her breath while assessing the FHR. Have the woman lie completely flat on her back while auscultating. Instruct the woman to bend her knees and flex her hips.
Palpate the mother's radial pulse at the same time.
A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? Lochia is less than usual. Bladder is nonpalpable. Percussion reveals dullness. Uterus is firm.
Percussion reveals dullness.
A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth? Avoid use of water-based gel lubricants. Resume intercourse if bright red bleeding stops. Avoid performing pelvic floor exercises. Use oral contraceptive pills (OCPs) for contraception.
Resume intercourse if bright red bleeding stops.
The nurse instructs the client about skin massage and the gate control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods? These methods are a technique to prevent the painful stimuli from entering the brain. The gating mechanism is located at the pain site. Pain perception is decreased if anxiety is present. The gating mechanism opens so all the stimuli pass through to the brain.
These methods are a technique to prevent the painful stimuli from entering the brain. (Gate-control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location. Gate control does not need to be applied directly to the site of the pain. Anxiety heightens the painful feelings. Gating blocks the flow of painful stimuli to the sensory centers in the brain.)
The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients?
Thoroughly wash the hands before and after client contact.
A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply. Turn the client on her left side. Administer oxygen by mask. Ignore questions from the client. Reduce intravenous (IV) fluid rate. Assess client for underlying causes.
Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.
A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? Walk with the nurse the length of her room. Avoid getting out of bed for another 2 days. Avoid elevating her feet when she rests in a chair. Walk the length of the hallway to regain her strength.
Walk with the nurse the length of her room.
Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? lochia appearing pinkish-brown on the fourth day lochia that is the color of menstrual blood an absence of lochia red-colored lochia for the first 24 hours
an absence of lochia
Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? red-colored lochia for the first 24 hours lochia that is the color of menstrual blood an absence of lochia lochia appearing pinkish-brown on the fourth day
an absence of lochia
A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client? a sitz bath an ice pack applied to the perineum opioid pain medication a heating pad applied to the perineum
an ice pack applied to the perineum
Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: increase the flow of an IV. assess and massage the fundus. call the primary care provider or the nurse-midwife. inspect the perineum for lacerations.
assess and massage the fundus.
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? infection atony hemorrhage normal involution
atony
A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? showing a video of parents feeding their babies bringing the newborn into the room talking about how the nurse held her own newborn while on the birthing table allowing the mother to pick the best time to hold her newborn
bringing the newborn into the room
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? fluid volume overload dehydration infection change in the temperature from the birth room
dehydration
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? first degree third degree fourth degree second degree
fourth degree
Which is the most important factor on how much admission data is obtained when a client reports to the hospital in labor?
imminence of birth
A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? hemorrhage pulmonary emboli depression infection
infection
A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? normal findings in breastfeeding mothers too much milk being retained mastitis an improperly positioned baby during feedings
mastitis
While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply. moderate lochia rubra rounded mass over symphysis pubis fundus boggy to the right of the umbilicus dullness on percussion over symphysis pubis elevated oral temperature
rounded mass over symphysis pubis dullness on percussion over symphysis pubis fundus boggy to the right of the umbilicus
To assess the frequency of a woman's labor contractions, the nurse would time: the interval between the acme of two consecutive contractions. the beginning of one contraction to the beginning of the next. how many contractions occur in 5 minutes. the end of one contraction to the beginning of the next.
the beginning of one contraction to the beginning of the next.
A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? "Sitz baths worked the last time." "I only eat a low-fiber diet." "I already have some pads with witch hazel at home." "My mom always used dibucaine."
"I only eat a low-fiber diet."
In the labor and delivery unit, which is the best way to prevent the spread of infection? Complete hand hygiene Limit vaginal examinations Use sterile gloves Provide clean gloves in the room
Complete hand hygiene
A nurse is to care for a client during the postpartum period. The client reports pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? Select all that apply. Nipples are fissured. Breasts are soft. Breasts are hard. Breasts are tender. Nipples are cracked.
Breasts are hard. Breasts are tender.
The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for analgesia. The nurse explains the analgesia usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice?
This may prolong labor and increase complications.
The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply. frequency of contractions change in temperature intensity of contractions change in blood pressure uterine resting tone
uterine resting tone frequency of contractions intensity of contractions
Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood." "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood." "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood."
"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."
On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? 750 additional calories per day 250 additional calories per day 500 additional calories per day 1,000 additional calories per day
500 additional calories per day
A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing: thrombophlebitis. mitral valve collapse. upper respiratory infection. pulmonary embolism.
pulmonary embolism.
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? infection hormonal shifting of relaxin and estrogen thromboembolic disorder of the lower extremities normal response to the body converting back to prepregnancy state
thromboembolic disorder of the lower extremities
The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? feeding talking touching looking
touching
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? noninvasive arterial studies of the right leg transthoracic echocardiogram venous duplex ultrasound of the right leg venogram of the right leg
venous duplex ultrasound of the right leg
The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. pain level vital signs of mother head-to-toe assessment newborn's vital signs head-to-toe assessment of newborn
vital signs of mother pain level head-to-toe assessment
A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response?
"Spinal headache is not a usual complication of epidural blocks."
A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? The color of the flow is red. The flow contains large clots. Her uterus is soft to your touch. The flow is over 500 mL.
The color of the flow is red.
Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother?
The mother may have difficulty working effectively with contractions. (Breathing and relaxation techniques can speed labor. An inability of the woman to do these as a result of pain relief measures can slow labor.)
Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: maintaining previous household routines to prevent infection. the client will show no signs of infection. listing signs of infection that she will report to her health care provider. discussing methods that the woman will use to prevent infection.
maintaining previous household routines to prevent infection.
A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: "Effleurage is the effect of a full bladder on fetal descent." "Effleurage is light abdominal massage used to displace pain." "Effleurage is the pattern for cleaning the perineum before birth." "Effleurage is massaging the perineum as the fetus enlarges the vaginal opening."
"Effleurage is light abdominal massage used to displace pain."
The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response? Print a copy of the instructions for the doula to sign Ask the client who she would like to see first Determine what activities the doula is qualified to handle Continue with the admission assessment
Continue with the admission assessment
A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? Apply ice packs directly to the perineal area. Use ice packs for a week after birth. Ensure ice pack is changed frequently. Apply ice packs for 40 minutes continuously.
Ensure ice pack is changed frequently.
While assessing the progress of the labor, the nurse explains that the fetal heart rate variability is moderate. Which explanation is best to use with the parents? FHR fluctuates from 6 to 25 beats per minute. FHR fluctuates less than 5 beats per minute. FHR fluctuates over 25 beats per minute. FHR fluctuation range is undetectable.
FHR fluctuates from 6 to 25 beats per minute.
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next? Maternal status Maternal obstetrical history Risk factors Fetal status
Fetal status
During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used.
-4 station -2 station 0 station +2 station +4 station
The client may spend the latent phase of the first stage of labor at home unless which occurs? The client begins back labor The contractions vary in length and intensity The client experiences a rupture of membranes The client passes the bloody show
The client experiences a rupture of membranes
Which procedure is contraindicated in an antepartum client with bright red, painless bleeding? Urinalysis Vaginal examination Leopold maneuver Nonstress test
Vaginal examination
A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply. passing gas active bowel sounds abdominal pain tender abdomen nondistended abdomen
active bowel sounds passing gas nondistended abdomen
The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy? biofeedback acupressure acupuncture effleurage
acupressure
The nurse explains Leopold maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. determining the presentation of the fetus determining the position of the fetus determining the weight of the fetus determining the size of the fetus determining the lie of the fetus
determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus
The nurse realizes that accommodating for the various cultural differences in her clients is an important aspect in providing their care. When caring for a postpartum woman of Japanese descent, which action would be a priority? providing time for prayers to be performed at the bedside ensuring that the newborn receives a daily bath allowing time for the numerous visitors who come to see the woman and newborn assigning a female nurse to care for her
ensuring that the newborn receives a daily bath
During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? generally within 3 to 6 weeks usually within a couple weeks generally after 12 weeks whenever the couple wishes
generally within 3 to 6 weeks
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia? headache following anesthesia excessive contractions of the uterus increased frequency of micturition passage of the drug to the fetus
headache following anesthesia
Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? hematoma infection DVT nothing—it is normal
hematoma
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening? hemorrhage pulmonary emboli infection fluid volume overload
hemorrhage
A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: light. moderate. heavy. scant.
moderate.
A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? placenta removed via manual extraction hemoglobin of 11.5 mg/dl (115 g/L) multiparity labor less than 3 hours
placenta removed via manual extraction
A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will: press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist. instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale. instruct the client or her partner to perform light fingertip repetitive abdominal massage. lead the client through a series of visualizations to aid in relaxation.
instruct the client or her partner to perform light fingertip repetitive abdominal massage.
A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately? respiratory rate 16 breaths/minute pulse rate 75 beats per minute oral temperature 100.8° F (38.2° C) uterine fundus 1 cm below umbilicus
oral temperature 100.8° F (38.2° C)
The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which action would the nurse include in the discussion as possible strategies for the new mothers to do? Select all that apply. avoiding smoking increasing fluid intake starting jogging losing weight if obese performing Kegel exercises
performing Kegel exercises avoiding smoking losing weight if obese
When palpating for fundal height on a postpartum woman, which technique is preferable? resting both hands on the fundus placing one hand at the base of the uterus, one on the fundus palpating the fundus with only fingertip pressure placing one hand on the fundus, one on the perineum
placing one hand at the base of the uterus, one on the fundus
The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process? policies that allow visitors policies that discourage unwrapping and exploring the infant policies that allow rooming the infant and mother together policies that allow flexibility for cultural differences
policies that discourage unwrapping and exploring the infant
In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. women on antithyroid medications women on antineoplastic medications women who had difficulties with breastfeeding in the past women using street drugs women with more than one infant
women on antithyroid medications women on antineoplastic medications women using street drugs
Prior to discharge is an appropriate time to evaluate the client's status for preventive measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh-negative mother? ANA indirect Coombs test titer screen CBC with differential
indirect Coombs test
The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring?
rupture of membranes
