621 Chp 15, 16, 22
B
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? a) Assist the woman into the shower, and have her run cold water over her breasts. b) Assist the woman in placing ice packs on her breasts. c) Explain to the woman that she should breastfeed because she is producing so much milk. d) Ask if she wants a breast pump to empty her breasts.
D
A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis? A) Assess for reddness and warmth. B) Ask about increased pain with weight bearing. C) Ask if she has pain or tenderness in the lower extremities. D) Dorsiflex her right foot and ask if she has pain in her calf.
B
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? A) urinary overflow B) postpartum diuresis C) urinary tract infection D) trauma to pelvic muscles
A
A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? A) Check the lochia. B) Assess the temperature. C) Monitor the pain level. D) Assess the fundal height.
B
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize? A) "This is normal; give it a few days and then call back." B) "After birth it is easier to develop an infection in the urinary system; we need to see you today." C) "Are you washing and providing good perineal hygiene? If not, this may be the reason for the irritation." D) "It is common for women to have yeast problems; try an over the counter cream and let us know if this continues."
B
A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? A) Avoid iron replacement therapy. B) Avoid over-the-counter (OTC) salicylates. C) Wear knee-high stockings when possible. D) Shortness of breath is a common adverse effect of the medication
C
A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: T 101.2° F; (38.4° C) HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs? A) dehydration B) normal vital signs C) infection D)shock
C
A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy? A) Sit with legs crossed over each other. B) Avoid prolonged straining during defecation. C) Avoid products containing aspirin. D) Refrain from performing any leg exercises.
C
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains? A) prolactin B) progesterone C) oxytocin D) estrogen
B
A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition? A) diabetes B) long-term obesity C) feelings of increased self-esteem D) increased sex drive
B
It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at: A) the level of the umbilicus. B) between the umbilicus and symphysis pubis. C) 1 cm below the umbilicus. D) 2 cm below the umbilicus.
C
The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis? A) Complete blood count B) Vital signs C) Pad count D)Urine volume excreted
D
The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? A) The most common pathogen is group A beta-hemolytic streptococci. B) A breast abscess is a common complication of mastitis. C) Mastitis usually develops in both breasts of a breastfeeding client. D) Symptoms include fever, chills, malaise, and localized breast tenderness.
D
The nurse observes an ambulating postpartal woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client? A) Bend the knee and palpate the calf for pain. B) Ask the client to raise the foot and draw a circle. C) Blanch a toe, and count the seconds it takes to color again. D) Assess for warmth, erythema, and pedal edema.
B
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: A) "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood." B) "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." C) "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." D) "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood."
D
Upon assessment, a nurse notes the client has a pulse of 90 bpm, moderate lochia, and a boggy uterus. What should the nurse do next? A) Notify the healthcare provider. B) Assess the client's blood pressure. C) Change the client's peri-pad. D) Massage the client's fundus.
D
Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate? A) She should stop breast-feeding until completing the antibiotic. B) She should supplement feeding with formula until the infection resolves. C) She should not use analgesics because they are not compatible with breast-feeding. D) She should continue to breast-feed; mastitis will not infect the neonate.
A
A nurse is caring for the client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. Which should the nurse do next? A) Tell the client to take an NSAID orally. B) Have the client stop breastfeeding. C) Instruct the client to take a warm shower. D) Ask how often the client is breastfeeding.
B
The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client? A) presence of lochia rubra B) fever more than 100.4° F (38° C) C) fundus is above the umbilicus D)fundus is firm
A, B, C
In a class for expectant parents, the nurse may discuss 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. A) women on antithyroid medications B) women on antineoplastic medications C) women using street drugs D) women with more than one infant E) women who had difficulties with breastfeeding in the past
A
In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication? A) deep venous thrombosis B) uterine atony C) postpartum hemorrhage D) metritis
A
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? A) policies that discourage unwrapping and exploring the infant B) policies that allow rooming the infant and mother together C) policies that allow visitors D) policies that allow flexibility for cultural differences
C
The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness? A) increased white blood cell count B) stirrup injury during birth C) increased coagulation factors D) decreased red blood cell count
A, C, D
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. A) vital signs of mother B) newborn's vital signs C) pain level D) head-to-toe assessment E) head-to-toe assessment of newborn
B
The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and: A) consistency. B) odor. C) specific gravity. D) pH.
B
The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage? A) Hematoma B) Uterine atony C) Perineal lacerations D) Disseminated intravascular coagulation
B
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? A) hemorrhage B) infection C) depression D) pulmonary emboli
A
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? A) "I only eat a low-fiber diet." B) "I already have some pads with witch hazel at home." C) "My mom always used dibucaine." D)"Sitz baths worked the last time."
B
A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? A) Notify the primary care provider, and document the findings. B) Have the client void, and then massage the fundus until it is firm. C) Assess a full set of vital signs. D) Check and inspect the lochia, and document all findings.
B
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? A) infection B) dehydration C) change in the temperature from the birth room D) fluid volume overload
B
On the third day postpartum, which temperature is internationally defined as a postpartal infection? A) 99.6° F (37.5° C) B) 100.4° F (38° C) C) 102.4° F (39.1° C) D) 104.2° F (40.1° C)
D
The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? A) Initiate Ringer's lactate infusion. B) Assess the woman's vital signs. C) Call the woman's health care provider. D) Assess the woman's fundus.
A
Upon assessment, the nurse notes a postpartum client has increased vaginal bleeding. The client had a forceps birth that resulted in lacerations 4 hours ago. What should the nurse do next? A) Assess for uterine contractions. B) Change the client's peri-pad. C) Obtain the client's vital signs. D) Have the client void.
D
Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? A) increasing oral fluid intake B) increasing intravenous fluids C) screening for bacteriuria in the urine D) encouraging the woman to empty her bladder completely every 2 to 4 hours
A
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? A) 500 additional calories per day B) 1,000 additional calories per day C) 250 additional calories per day D) 750 additional calories per day
A
Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts? A) applying ice B) restricting fluids C) applying warm compresses D) administering bromocriptine
B
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge teaching to address this issue? A) "You may have intercourse until next month with no fear of pregnancy." B) "Ovulation may return as soon as 3 weeks after birth." C) "You will not ovulate until your menstrual cycle returns." D) "Ovulation does not return for 6 months after birth."
A
What postpartum client should the nurse monitor most closely for signs of a postpartum infection? A) A client who had a nonelective cesarean birth B) A primaparous client who had a vaginal birth C) A client who had an 8-hour labor D) A client who conceived following fertility treatments
C
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? A) a scant amount of lochia alba B) a moderate amount of lochia alba C) a moderate amount of lochia rubra D) a scant amount of lochia serosa
B
Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis? A) edema in perineal area B) redness in lower legs C) diaphoresis D) increased lochia
C
A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? A) hyperglycemia B) hypertension C) hypovolemia D) hypothyroidism
1, 2, 3, 4, 5, 6
A client who gave birth 18 hours ago is experiencing a change in lochia flow from scant to moderate. Prioritize the actions the nurse would take to assess the client's fundus. All options must be used. 1 Assist the client to empty her bladder in the bathroom. 2 Palpate the fundus. 3 Massage the fundus if boggy. 4 Increase IV oxytocin or breastfeed the newborn. 5 Assess blood pressure. 6 Notify the primary care provider.
B
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? A) Avoid use of water-based gel lubricants. B) Resume intercourse if bright red bleeding stops. C) Avoid performing pelvic floor exercises. D) Use oral contraceptives for contraception.
A
A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue? A) Hold the baby frequently. B) Speak to his friends who have children. C) Read up on parental care. D) Have the client speak to the primary care provider on her husband's behalf
A
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? A) postpartum psychosis B) postpartum blues C) postpartum depression D) postpartum panic disorder
C
Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? A) Avoid massaging the breast area. B) Avoid frequent breast-feeding. C) Perform handwashing before breast-feeding. D) Apply cold compresses to the breast.