Maternal Newborn Success Chapter 7
48. The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."
#####2. This statement is accurate. Mothers often do not feel bladder pressure af ter delivery.
60. The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? 1. Teach baby care skills like diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills like pumping.
####2. During the taking in phase, clients need to internalize their labor experi ences. Discussing the labor process is appropriate for this postpartum phase.
73. The third stage of labor has just ended for a client who has decided to bottlefeed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.
####2. Prolactin will elevate sharply in the client's bloodstream.
42. A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.
####2. The nurse should stabilize the base of the uterus with his or her dependent hand.
87. During a postpartum assessment, the nurse performs a Homan's sign. Which of the following actions does the nurse perform? 1. Taps the patellae with a reflex hammer. 2. Dorsiflexes the feet. 3. Palpates the calves and ankles. 4. Monitors the color of the extremities.
####2. The nurse would dorsiflex the feet when performing Homan's sign.
38. The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.
####2. The nurse would expect to see well approximated edges.
30. A woman is receiving patient-controlled analgesia (PCA) post-cesarean section. Which of the following must be included in the patient teaching? 1. The client should monitor how often she presses the button. 2. The client should report any feelings of nausea or itching to the nurse. 3. The family should press the button whenever they feel the woman is in pain. 4. The family should inform the nurse if the client becomes sleepy.
####2. This information is correct. Clients often experience nausea and/or itching when PCA narcotics are administered.
64. A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.
####2. This information is correct. The blues usually resolve within 2 weeks of delivery.
85. The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate? 1. Irrigate the incision twice daily. 2. Monitor the incision for drainage. 3. Apply steristrips to the incision line. 4. Palpate the incision for weaknesses. 86. A nurse is performing a postpartum assessment on a newly delivered client. Which
####2. This is appropriate. The nurse should assess for all signs on the REEDA scale.
76. A client who delivered a 3900-gram baby vaginally over a right lateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."
####2. This is the best response. A right lat eral episiotomy runs perpendicular to the perineum.
62. The nurse takes a primipara her newborn for a feeding. The client holds the baby en face, strokes his cheek, and states that this is the first infant she has ever held. Which of the following nursing assessments is most appropriate? 1. Positive bonding and client needs little teaching. 2. Positive bonding but teaching related to infant care is needed. 3. Poor bonding and referral to a child abuse agency is essential. 4. Poor bonding but there is potential for positive mothering.
####2. This response is correct. The client is showing signs of positive bonding—en face positioning and stroking of the baby's cheeks—and is in need of infor mation on child care.
81. Why are obstetric clients most at high risk for cardiovascular compromise during the one hour immediately following a delivery? 1. Because the weight of the uterine body is significantly reduced. 2. Because the excess blood volume from pregnancy is circulating in the woman's periphery. 3. Because the cervix is fully dilated and the lochia flows freely. 4. Because the maternal blood pressure drops precipitously once the baby's head emerges.
####2. This response is true. Once the pla centa is birthed, the reservoir for the mother's large blood volume is gone. .
36. A post-cesarean section, breastfeeding client, whose subjective pain level is 2/5, requests her as needed (prn) narcotic analgesics every 3 hours. She states, "I have decided to make sure that I feel as little pain from this experience as possible." Which of the following should the nurse conclude in relation to this woman's behavior? 1. The woman needs a stronger narcotic order. 2. The woman is high risk for severe constipation. 3. The woman's breast milk volume may drop while taking the medicine. 4. The woman's newborn may become addicted to the medication.
####2. This statement is correct. One of the common side effects of narcotics is constipation.
50. The nurse has taught a new admission to the postpartum unit about pericare Which of the following indicates that the client understands the procedure? 1. The woman performs the procedure twice a day. 2. The woman sits in warm tap water for ten minutes. 3. The woman sprays her perineum from front to back. 4. The woman mixes tap water with hydrogen peroxide.
####2. When a client sits in a warm water bath, she is taking a sitz bath.
72. The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.
####3. Cramping is an expected outcome of the administration of Methergine. .
51. The nurse informs a postpartum woman that ibuprofen (Advil) is especially effec tive for afterbirth pains. What is the scientific rationale for this? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen is administered in high doses.
####3. Ibuprofen is administered orally.
47. The nurse is examining a 2-day postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.
####3. Normal involution, lochia rubra moderate.
70. A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.
####3. The blood pressure should be assessed before administering Methergine.
63. A primipara, 4 hours postpartum, requests that the nurse diaper her baby after a feeding because, "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is ex hibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.
####3. The client is exhibiting normal post partum behavior.
44. The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider? 1. White blood cells—12,500 cells/mm3. 2. Red blood cells—4,500,000 cells/mm3. 3. Hematocrit—26%. 4. Hemoglobin—11 g/dL
####3. The client's hematocrit is well below normal. This value should be reported to the client's health care provider.
65. A 2-day postpartum mother, G2P2002, states that her 2-year-old daughter at home is very excited about taking "my baby sister" home. Which of the following is an appropriate response by the nurse? 1. "It's always nice when siblings are excited to have the babies go home." 2. "Your daughter is very advanced for her age. She must speak very well." 3. "Your daughter is likely to become very jealous of the new baby." 4. "Older sisters can be very helpful. They love to play mother."
####3. The nurse should forewarn the mother about the likelihood of the 2-year-old's jealousy.
54. On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was as sessed at 11.0 gm/dL, and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? 1. Hgb 12.5 gm/dL; Hct 37%. 2. Hgb 11.0 gm/dL; Hct 33%. 3. Hgb 10.5 gm/dL; Hct 31%. 4. Hgb 9.0 gm/dL; Hct 27%.
####3. The nurse would expect these values—a slight decrease in both hemoglobin and hematocrit values.
53. A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? 1. Skim milk. 2. Ginger ale. 3. Orange juice. 4. Chamomile tea.
####3. The nurse would recommend that the iron be taken with orange juice be cause ascorbic acid, which is in orange juice, promotes the absorption of iron into the body.
79. A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant? 1. Assess client's fundal height. 2. Teach client how to massage her fundus. 3. Take the client's vital signs. 4. Document quantity of lochia in the chart.
####3. This action can be delegated to a nursing assistant. Once the vital signs are checked, the nursing assistant can report the results to the nurse for his or her interpretation.
80. A client, G2P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.
####3. This action is very important. If the legs are removed from the stirrups one at a time, the woman is at high risk for back and abdominal injuries.
66. The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terri ble. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Posttrauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.
####3. This diagnosis is appropriate. This client is showing signs of postpartum blues; one of the main reasons for this problem is related to the hormonal changes that occur after delivery.
78. A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.
####3. This is the most important goal during the immediate postdelivery period.
40. The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on third postpartum day. 2. Administer analgesics every four hours per doctor orders. 3. Teach client to contract her buttocks before sitting. 4. Irrigate incision twice daily with antibiotic solution.
####3. This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the su ture line.
4. To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with a povidone-iodine solution after toileting.
. 2. Clients should be advised to change their pads at each voiding.
5. A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.
1. Clients should be strongly encouraged exclusively to breastfeed their babies to prevent engorgement.
10. The nurse in the obstetric clinic received a telephone call from a bottlefeeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary health care provider to order a milk suppressant.
1. The client should apply ice packs to her axillae and breasts.
2. A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse's response? 1. The client's obstetric status is optimal for receiving the vaccine. 2. The client's immune system is highly responsive during the postpartum period. 3. The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine. 4. The client's insurance company will pay for the shot if it is given during the immediate postpartum period.
1. This statement is correct. Because the vaccine is teratogenic, the best time to administer it is when the client is not pregnant.
1. A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine? 1. The woman should not become pregnant for at least 4 weeks. 2. The woman should pump and dump her breast milk for 1 week. 3. The mother must wear a surgical mask when she cares for the baby. 4. Passive antibodies transported across the placenta will protect the baby
1. This statement is correct. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if the woman becomes pregnant within 4 weeks of receiving the injection.
16. A client who is 3 days postpartum asks the nurse, "When may my husband and I begin having sexual relations again?" The nurse should encourage the couple to wait until after which of the following has occurred? 1. The client has had her six-week postpartum check-up. 2. The episiotomy has healed and the lochia has stopped. 3. The lochia has turned to pink and the vagina is no longer tender. 4. The client has had her first postpartum menstrual period
16.#### 1. This response is correct. The couple is encouraged to wait until after invo lution is complete.
26. A breastfeeding client, G10P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.
2. An assessment of the woman's fundus is the most important assessment to perform on this client.
18. The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.
3. The blood volume does drop precipi tously during the early postpartum period.
24. During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.
2. The nurse would expect that the client would have lochia alba.
20. Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit 39%. 2. White blood cell count 16,000 cells/mm3 . 3. Red blood cell count 5 million cells/mm3 . 4. Hemoglobin 15 grams/dL.
2. The nurse would expect to see an ele vated white cell count.
14. Which of the following statements is true about breastfeeding mothers as compared to bottlefeeding mothers? 1. Breastfeeding mothers usually involute completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.
2. There is evidence to show that women who breastfeed their babies are less likely to develop type 2 dia betes later in life
49. A client, G1P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and de viated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary health care provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.
2. This action is the first that the nurse should take.
22. The nurse is discussing the importance of doing Kegel exercises during the postpartum period. Which of the following should be included in the teaching plan? 1. She should repeatedly contract and relax her rectal and thigh muscles. 2. She should practice by stopping the urine flow midstream every time she voids. 3. She should get on her hands and knees whenever performing the exercises. 4. She should be taught that toned pubococcygeal muscles decrease blood loss.
2. This is a correct statement.
15. A breastfeeding woman, 11 ⁄2 months postdelivery, calls the nurse in the obstetrician's office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection reflex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk
2. This is true. Oxytocin stimulates sexual orgasms and is also the hormone that stimulates the milk ejection reflex.
6. A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.
2. This statement is true. The best way to prevent engorgement is to feed the baby every 2 to 3 hours.
28. The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum
28. ####1. It is appropriate to apply an ice pack to the area.
19. A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Inform the neonate's pediatrician
3. Diaphoresis is normal during the postpartum period.
13. A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate infant positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.
3. Rotating positions at feedings is one action that can help to minimize the severity of sore nipples.
27. The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.
3. The woman should turn, cough, and deep breathe every 2 hours.
25. The day after delivery a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong, "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.
3. This response is correct. Polyuria is normal.
17. A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done something terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, I bet you have a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in for an assessment?"
3. This response is correct. The woman should be encouraged to use a lubri cating jelly or oil.
31. The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance the day before. The baby's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? 1. "Sometimes babies just don't deliver the way we expect them to." 2. "With all of your preparations, it must have been disappointing for you to have had a cesarean." 3. "I know you had to have surgery, but you are very lucky that your baby was born healthy." 4. "At least your husband was able to be with you when the baby was born."
31####. 1. This comment is inappropriate. It does not acknowledge the client's likely disap pointment about having to have a ce sarean section.
32. A postoperative cesarean section woman is to receive morphine 4 mg q 3-4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? ___________ mL
32. 0.6 mL
33. The obstetrician has ordered that a post-op cesarean section client's patientcontrolled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate? 1. Discard the remaining medication in the presence of another nurse. 2. Recommend waiting until her pain level is zero to discontinue the medicine. 3. Discontinue the medication only after the analgesia is completely absorbed. 4. Return the unused portion of medication to the narcotics cabinet.
33. ####1. This answer is correct. Because the medication in a PCA pump is con trolled by law, the medication must be wasted in the presence of another nurse.
34. A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? 1. Respiratory rate 8 rpm. 2. Complaint of thirst. 3. Urinary output of 250 cc/hr. 4. Numbness of feet and ankles.
34.#### 1. This action is appropriate. This client's respiratory rate is below normal.
67. A Muslim woman requests something to eat after the delivery of her baby. Which of the following meals would be most appropriate for the nurse to give her? 1. Ham sandwich. 2. Bacon and eggs. 3. Spaghetti with sausage. 4. Chicken and dumplings.
4. Although this is not a traditional Muslim dish, the foods are allowable by Muslim tradition.
8. A G2P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider.
4. Because of the heavy lochia, the nurse should notify the woman's health care provider.
12. The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? 1. 1⁄2 cup raw celery dipped in 1 ounce cream cheese. 2. 8 ounce yogurt mixed with 1 medium banana. 3. 12 ounce strawberry milk shake. 4. 11⁄2 cup raw broccoli.
4. Broccoli is very high in vitamin A and also contains iron.
61. The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother.
4. Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby.
35. A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement." 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."
4. Consuming fluids and fiber and exer cising all help clients to reestablish normal bowel function.
23. The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.
4. The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3.
3. A patient, G2P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2ºF. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.
4. It is likely that this client is dehydrated. She should be advised to drink fluids.
7. A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."
4. Many mothers who consume approximately the same number of calories while breastfeeding as they did when they were pregnant do lose weight while breastfeeding.
9. A client informs the nurse that she intends to bottlefeed her baby. Which of the following actions should the nurse encourage the client to perform? 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day.
4. The mother should be advised to wear a supportive bra 24 hours a day for a week or so.
11. A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her infant. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottlefeed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.
4. The nurse should discuss the action of oxytocin.
37. A nurse is assessing a 1-day postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes
4. This blood loss is excessive, especially for a postoperative cesarean section client. The surgeon should be notified.
75. The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6˚F, 82, 18; fundus firm at umbilicus; moderate lochia; ambulated to bathroom to void 4 times; breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? 1. Fluid volume deficit r/t excess blood loss. 2. Impaired skin integrity r/t vaginal delivery. 3. Impaired urinary elimination r/t excess output. 4. Knowledge deficit r/t lack of parenting experience.
4. This client is a primigravida. The nurse would anticipate that she is in need of teaching regarding infant care as well as self-care.
41. A client, G1P1001, 1-hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.
4. This is the appropriate action by the nurse.
29. A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse's best response? 1. "I know that it hurts but it is very important for you to cough." 2. "Let me check your lung fields to see if coughing is really necessary." 3. "If you take a few deep breaths in, that should be as good as coughing." 4. "If you support your incision with a pillow, coughing should hurt less."
4. This is the appropriate response. The nurse is providing the client with a means of reducing the discomfort of postsurgical coughing.
45. A bottlefeeding woman, 11⁄2 weeks postpartum from a vaginal delivery, calls the ob stetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1. "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." 2. "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." 3. "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." 4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."
4. This response is appropriate. The client should be examined to assess her involution.
83. The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, "Oh, I don't use those. I always use tampons." Which of the following actions by the nurse is appropriate at this time? 1. Remove the peripad and insert a tampon into the woman's vagina. 2. Advise the client that for the first two days she will be bleeding too heavily for a tampon. 3. Remind the client that a tampon would hurt until the soreness from the delivery resolves. 4. State that it is unsafe to place anything into the vagina until involution is complete.
4. This response is correct. It is unsafe to place anything in the vagina before involution is complete.
39. A client, G1P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."
4. This response shows that the nurse has an understanding of the client's feelings.
46. A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? 1. "You must wait to begin to perform exercises until after your six-week postpar tum checkup." 2. "You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe." 3. "By next week you will be able to return to the exercise schedule you had during your prepregnancy." 4. "You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks."
4. This statement is correct. The client should begin with Kegel exercises shortly after delivery, move to ab dominal tightening exercises in the next couple of days, and then slowly progress to stomach crunches, and so on.
43. A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections.
43. ####1. This response is correct. Reassuring the client is appropriate.
55. During a postpartum assessment, it is noted that a G1P1001 woman, who delivered vaginally over an intact perineum, has a cluster of hemorrhoids. Which of the follow ing would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure.
55. 1, 2, and 5 are correct. ####1. Sitz baths do have a soothing affect for clients with hemorrhoids. ####2. Clients often feel some relief when external hemorrhoids are reinserted into the rectum. ####5. Topical anesthetics can provide relief from the discomfort of hemorrhoids.
56. Which of the following is the priority nursing action during the immediate post partum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.
56.#### 1. Fundal assessment is the priority nursing action.
57. Immediately after delivery, a woman is shaking uncontrollably. Which of the fol lowing nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in Trendelenburg position. 3. Notify the primary health care provider. 4. Increase the intravenous infusion.
57.#### 1. The appropriate action is to provide the client with warm blankets.
58. One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this di agnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.
58. 2, 3, and 4 are correct. ####2. An important goal is that the woman's WBC will remain stable. ####3. An important goal is that the woman's temperature will remain normal. ####4. An important goal is that the woman's lochia will smell normal.
59. Which of the following nursing interventions would be appropriate for the nurse to perform in order to achieve the client care goal: The client will not develop post partum thrombophlebitis? 1. Encourage early ambulation. 2. Promote oral fluid intake. 3. Massage the legs of the client twice daily. 4. Provide the client with high fiber foods.
59. ####1. Early ambulation does help to prevent thrombophlebitis.
68. The nurse is caring for a Seventh Day Adventist woman who delivered a baby boy by cesarean section. Which of the following questions should be asked regarding this woman's care? 1. "Would you like me to order a vegetarian clear liquid diet for you?" 2. "Is there anything special you will need for your Sabbath on Sunday?" 3. "Would you like to telephone your clergy to set up a date for the baptism?" 4. "Will a rabbi be performing the circumcision on your baby?"
68. ####1. This question is appropriate. Seventh Day Adventists usually follow vegetar ian diets.
69. An Asian client's temperature 10 hours after delivery is 100.2ºF. She refuses to drink her iced water. Which of the following actions is most appropriate? 1. Replace the iced water with hot water. 2. Notify the client's health care provider. 3. Assess the client's breasts for engorgement. 4. Remind the client that drinking is very important.
69.#### 1. This action is appropriate. Asians, many of whom believe in the hot-cold theory of disease, will often not drink cold fluids or eat cold foods during the postpartum.
71. Which of the following complementary therapies can a nurse suggest to a multi parous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink iced tea with lemon or lime.
71.#### 1. Lying prone on a pillow helps to re lieve some women's afterbirth pains.
74. The nurse has provided teaching to a post-op cesarean client who is being dis charged on Colace (docusate sodium) 100 mg po tid. Which of the following would indicate that the teaching was successful? 1. The woman swallows the tablets whole. 2. The woman takes the pills between meals. 3. The woman calls the doctor if she develops a headache. 4. The woman does not worry when her urine turns orange.
74.#### 1. Colace capsules should not be crushed, broken, or chewed.
77. After a client's placenta is birthed, the obstetrician states, "Please add 20 units of oxytocin to the intravenous and increase the drip rate to 250 cc/hr." The client has 750 cc in her IV and the IV tubing delivers fluid at the rate of 10 gtt/cc. To what drip rate should the nurse set the intravenous? ______ gtt/min
77. 42 gtt/min
82. The nurse is initiating discharge teaching with a couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple: 1. on admission to the labor room. 2. in the client room after the delivery. 3. when the client put the baby to the breast for the first time. 4. the day before the client and baby are to leave the hospital.
82. ####1. Discharge teaching should be initiated at the time of admission. This nurse is correct in initiating the process in the labor room.
84. A client has been transferred to the post-anesthesia care unit from a cesarean deliv ery. The client had spinal anesthesia for the surgery. Which of the following inter ventions should the nurse perform at this time? 1. Assess the level of the anesthesia. 2. Encourage the client to urinate in a bedpan. 3. Provide the client with the diet of her choice. 4. Check the incision for signs of infection.
84.#### 1. This answer is correct. The nurse should assess the level of anesthesia every 15 minutes while in the postanesthesia care unit.
86. A nurse is performing a postpartum assessment on a newly delivered client. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.
86. 1, 3, 4, and 5 are correct. ####1. The nurse should palpate the breasts to assess for fullness and/or engorgement. ####3. The nurse should check the client's vaginal discharge. ####4. The nurse should assess the client's extremities. ####5. The nurse should inspect the client's perineum.