Maternal Newborn Success - Normal Postpartum & High Risk Postpartum

A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? select all that apply 1. Hyperthermia 2. Diarrhea 3. Hypotension 4. Palpitations 5. Ansarca

*1. Hyperthermia *2. Diarrhea

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 1. Hallucinations. 2. Polyphagia. 3. Induced vomiting. 4. Weepy sadness.

*1. The client with postpartum psychosis will experience hallucinations. 2. Clients with diabetes mellitus, not postpartum psychosis, are polyphagic. 3. Clients with bulimia induce vomiting. 4. Clients with postpartum blues and/or postpartum depression are weepy and sad.

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 diagnosis? 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.

1. Although clients should drink fluids, this is not a goal related to the identified nursing diagnosis. *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. 5. Sitz baths are not given to prevent infections. They do help to soothe the pain and/or the inflammation associated with episiotomies and hemorrhoids.

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.

1. Diaphoresis has usually subsided by this time. *2. The nurse would expect that the client would have lochia alba. 3. The nurse would not expect the client's nipples to be cracked. 4. The nurse would not expect the client to be hypertensive.

The nurse informs a postpartum woman that ibuprofen (Advil) is especially effective 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.

1. Ibuprofen is usually administered every 4 to 6 hours. 2. This statement is correct. Ibuprofen has an antiprostaglandin effect. *3. Ibuprofen is administered orally. 4. This is not the reason why ibuprofen is especially effective for postpartum cramping.

A client who received a spinal for her cesarean delivery is complaining of pruritus and has a macular rash on her face and arms. Which of the following medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Zofran (ondansetron). 3. Compazine (prochlorperazine). 4. Benadryl (diphenydramine).

1. Reglan is an antiemetic. It is not the appropriate medication for this client. 2. Zofran is an antiemetic. It is not the appropriate medication for this client. 3. Compazine is an antiemetic. It is not the appropriate medication for this client. *4. Benadryl is an antihistamine. It is the drug of choice for this client who has pruritus and a rash.

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 exhibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

1. The client is not exhibiting signs of social isolation. 2. The client is not exhibiting signs of child neglect. *3. The client is exhibiting normal postpartum behavior. 4. The client is not exhibiting signs of postpartum depression.

A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? 1. Place the client flat in bed. 2. Assess for dependent edema. 3. Auscultate lung fields. 4. Check patellar reflexes.

1. The client should not be placed flat in bed. Her bed should be placed in the Sims position to enable her to aerate well. 2. There is nothing in the scenario that suggests that this client is high risk for dependent edema. *3. It is important for the nurse to auscultate the client's lung fields every 4 hours to assess for rales. 4. There is nothing in the scenario that suggests that this client is high risk for an alteration in reflex response.

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.

1. The client's subjective pain level is 2/5. It is unlikely that she needs stronger medication. *2. This statement is correct. One of the common side effects of narcotics is constipation. 3. This statement is incorrect. As long as the client feeds her baby frequently, the use of narcotics should not affect her milk production. 4. This statement is incorrect. This client's narcotic use is short term. Postoperative narcotic medications are considered safe for the breastfeeding baby. If the mother were a chronic narcotic user, the baby's response would be a concern.

The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? 1. Ineffective lactogenesis. 2. Dysfunctional parenting. 3. Wound dehiscence. 4. Projectile vomiting.

1. There is nothing in this client's history that would indicate that she could not produce breast milk. 2. There is nothing in this client's history that would indicate that she is at high risk for dysfunctional parenting. *3. This client is at high risk for wound dehiscence. Her wound healing may be impaired because of her diabetes and because of her obesity. 4. There is nothing in this client's history that would indicate that she is at high risk for projectile vomiting.

A mother, G4P4004, is 15 minutes postpartum. Her baby weighed 4595 grams at birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis.

1. This client is not especially at high risk for seizures. *2. The client should be monitored carefully for signs of postpartum hemorrhage. 3. This client is not especially at high risk for infection. 4. This client is not especially at high risk for thrombosis.

A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery complains of burning on urination. 2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO3 from cesarean delivery complains of firm and painful breasts.

1. This client must be assessed—she likely has a urinary tract infection (UTI)—but another client should be checked first. 2. This client must be assessed—although her blood loss is within normal limits— but another client should be checked first. *3. This client should be assessed first. The hemoglobin level is well below normal. 4. This client must be assessed—she is likely engorged—but another client should be checked first.

A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is, "Bleeding and saturating a pad about every 1⁄2 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bed rest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please come in whenever you are ready."

1. This response is not appropriate. It is unlikely that this client is menstruating at 2 weeks postpartum. 2. This response is not appropriate. This client needs to be evaluated. 3. This response is not appropriate. This is an unlikely explanation for the bleeding. *4. This is the correct response. This client needs to be evaluated.

The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0ºF, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings? 1. Temperature is elevated, a sign of infection. 2. Pulse is too low, a sign of vagal pathology. 3. Respirations are too low, a sign of medication toxicity. 4. Blood pressure is elevated, a sign of preeclampsia.

1. This temperature elevation does not indicate infection. 2. A low pulse rate is expected in the early postpartum period. *3. The respiratory rate of 12 is well below normal. Peripartum clients' respiratory rates average 20 rpm. 4. Although the systolic pressure is slightly elevated, a BP of 130/80 is within normal limits.

Cloxacillin 500 mg by mouth four times per day for 10 days has been ordered for a client with a breast abscess. The client states that she is unable to swallow pills. The oral solution is available as 125 mg/5 mL. How many mL of medicine should the woman take per dose? ______ mL per dose.

20 mL per dose

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.

64. 1. Fathers have not been shown to experi ence postpartum blues. ####2. This information is correct. The blues usually resolve within 2 weeks of delivery. 3. Medications are usually not administered to relieve postpartum blues. Medications can be prescribed for clients who experi ence postpartum depression or postpar tum psychosis. 4. This information is incorrect. The majority of women will experience post partum blues during the first week or 2 postpartum.

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. 2. This action is not necessary at this time. 3. This action is not indicated by the infor mation in the scenario. 4. This information is correct but it does not take into consideration the client's beliefs and traditions.

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. 2. Contracting the abdominal muscles has not been shown to alleviate afterbirth pains. 3. Ambulation has not been shown to alle viate afterbirth pains. 4. Drinking ice tea has not been shown to alleviate afterbirth pains.

72. A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding? 1. Have the woman wean the baby to formula. 2. Have the baby stay in the hospital room with the mother. 3. Have the woman pump and dump her milk for two weeks. 4. Have the baby bottlefed milk that the mother has stored.

72. 1. It is unnecessary to wean the baby to formula. 2. Optimally, the baby should stay in the hospital room with the mother. 3. It is unnecessary for the mother to pump and dump for 2 weeks. 4. Although the baby could drink milk stored by the mother, this is not the best solution.

77. A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis.

77. 1. This client is high risk for uterine atony. 2. The client is not at high risk for hypoprolactinemia. 3. The client is not at high risk for infection. 4. The client is not at high risk for mastitis.

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

80. A nurse is assessing a 1 day-postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10 point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic.

80. 1. The client should be assessed by her health care practitioner. 2. The client may need a sitz bath, but should be assessed first. 3. It is unlikely that this client has a hidden laceration since her lochial flow is normal. 4. The client may benefit from a narcotic, but should be assessed first.

A client is 1-day post-cesarean delivery for eclampsia. The client is receiving 5% dextrose in 1⁄2 normal saline IV at 125 cc/hr and magnesium sulfate IV via infusion pump. Which of the following laboratory values should the nurse report to the surgeon? 1. Serum magnesium 7 mg/dL. 2. Serum sodium 136 mg/dL. 3. Serum potassium 3.0 mg/dL. 4. Serum calcium 9 mg/dL.

1. A magnesium level of 7 mg/dL is therapeutic. This is an expected level. 2. The serum sodium level is normal. *3. The serum potassium is below normal. The nurse should report the finding to the physician. 4. The serum calcium is normal.

A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose? 1. Vitamin K. 2. Protamine. 3. Vitamin E. 4. Mannitol.

1. Vitamin K is the antidote for Coumadin (Warfarin) overdose, not for heparin overdose. *2. Protamine is the antidote for heparin overdose. 3. Vitamin E is not correct. 4. Mannitol is not correct.

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.

66. 1. This diagnosis is inappropriate. There is no indication that this client is suicidal or psychotic. 2. This diagnosis is inappropriate. There is no indication in the scenario that the client had a traumatic delivery. ####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. 4. This diagnosis is inappropriate. Nothing in the scenario implies that the client is in spiritual difficulties.

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.

73. 1. Estrogen drops precipitously after the placenta is delivered. ####2. Prolactin will elevate sharply in the client's bloodstream. 3. Human placental lactogen drops precipi tously after the placenta is delivered. 4. Human chorionic gonadotropin is pro duced by the fertilized ovum.

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."

76. 1. This is not the best response because the answer implies that the stitches are near the rectum. The stitches are not near the rectal area. ####2. This is the best response. A right lat eral episiotomy runs perpendicular to the perineum. 3. This is not the best response because the answer implies that the stitches are near the rectum. The stitches are not near the rectal area. 4. This is not the best response because the answer implies that the stitches are near the rectum. The stitches are not near the rectal area.

A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved? 1. Moderate lochia flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus above the umbilicus.

*1. A moderate lochia flow would indicate that the action was successful. 2. Decreased pain is not an expected outcome of uterine massage for uterine atony. 3. A stable postpartum blood pressure is not directly related to the action of uterine massage. 4. The expected outcome would be that the uterus is contracted at or below the umbilicus

A client is receiving a blood transfusion after the delivery of a placenta acreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion? 1. "My lower back hurts all of a sudden." 2. "My hands feel so cold." 3. "I feel like my heart is beating fast." 4. "I feel like I need to have a bowel movement."

*1. Sudden lower back pain is a sign of a transfusion reaction. 2. This is not a sign of a transfusion reaction. The client may be nervous about receiving the blood. 3. This is not a sign of a transfusion reaction. The client may be nervous about receiving the blood. 4. This is not a sign of a transfusion reaction. The client is likely having a normal bowel movement.

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? 1. Gently massage the areas toward the nipple especially during feedings. 2. Apply ice to the areas between feedings. 3. Bottlefeed for the next twenty-four hours. 4. Apply lanolin ointment to the areas after each and every breastfeeding.

*1. This answer is correct. She should gently massage the area toward the nipple. 2. The woman should apply warm soaks, not ice. 3. The woman should be advised to feed her baby frequently at the breast. She should not be advised to bottlefeed. 4. The woman should apply lanolin (Lansinoh) to sore or cracked nipples, not for a problem of tender hard nodules.

A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for last 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.

*1. This output is below the accepted minimum for 8 hours. 2. This weight decrease following delivery is within normal limits. 3. A 2% drop in hematocrit is within normal limits. 4. This pulse rate is within normal limits.

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.

1. A temperature of 100.2ºF is not a febrile temperature. It is unlikely that this client needs acetaminophen. 2. A temperature of 100.2ºF is not a febrile temperature. It is unlikely that this client is infected. 3. A temperature of 100.2ºF is not a febrile temperature. It is unlikely that this client needs cool compresses. *4. It is likely that this client is dehydrated. She should be advised to drink fluids.

A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication? 1. Chamomile tea can potentiate the affect of the drug. 2. Therapeutic effect may be delayed a week or more. 3. The medication should only be taken whole. 4. A weight gain of up to ten pounds is commonly seen.

1. Chamomile tea has not been shown to potentiate the affect of Zoloft, but St. John's wart has. *2. The therapeutic effect of selective serotonin receptor inhibitors (SSRIs) like Zoloft is delayed about 1 to 2 weeks from the time the medication is initiated. 3. This response is incorrect. The medication can be crushed. 4. A 10-lb weight gain is not associated with the medication.

The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug? 1. Monitor the urinary output hourly. 2. Supervise while the woman holds her newborn. 3. Position the woman slightly elevated on her left side. 4. Ask any visitors to leave the room.

1. It is unnecessary to monitor the client's hourly urinary output. *2. This is an appropriate action. 3. It is unnecessary for the client to be placed in this position. 4. It is unnecessary for visitors to leave the client's room.

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.

1. The client should ambulate. There is nothing in the scenario indicating that the client must use a bedpan. 2. It is likely that the client needs to urinate. 3. In-dwelling catheters are rarely inserted for vaginal deliveries. *4. This is the appropriate action by the nurse.

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.

1. The client should perform pericare at each toileting and whenever she changes her peripad. *2. When a client sits in a warm water bath, she is taking a sitz bath. 3. This statement is accurate. 4. Hydrogen peroxide is not added to a perineal irrigation bottle (peri bottle).

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.

1. The hematocrit is often low in postpartum clients. *2. The nurse would expect to see an elevated white cell count. 3. The red cell count is often low in postpartum clients. 4. The hemoglobin is often low in postpartum clients.

Which of the following comments suggest that a client, whose baby was born with a congenital defect, is in the bargaining phase of grief? 1. "I hate myself. I caused my baby to be sick." 2. "I'll take him to a specialist. Then he will get better." 3. "I can't seem to stop crying." 4. "This can't be happening."

1. This client is voicing anger at herself. *2. This client is exhibiting the bargaining stage of grief. 3. This client is exhibiting signs of depression. 4. This client is exhibiting denial.

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

1. This fundal height is within normal limits. Clients who have had cesarean sections often involute at a slightly slower pace than clients who have had vaginal deliveries. 2. This finding is normal. Pregnant clients and clients in the early postpartum period have nodular breasts in preparation for lactation. 3. This pulse rate is normal. Once the placenta is delivered, the reservoir for the large blood volume is gone. Clients often develop bradycardia as a result. *4. This blood loss is excessive, especially for a postoperative cesarean section client. The surgeon should be notified.

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.

1. To perform Kegel exercises, the client should be advised to contract and relax the muscles that stop the urine flow. *2. This is a correct statement. 3. Kegel exercises can be performed in any position. 4. Lochia flow is unaffected by contracting the pubococcygeal muscles.

A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk? 1. Hemorrhage. 2. Stroke. 3. Endometritis. 4. Hematoma.

1. When a client has DVT she is clotting excessively. She is not at high risk for hemorrhage. *2. The client is at high risk for stroke if a clot should travel to the brain through the vascular tree. 3. The client is not at high risk for endometritis if she has DVT. 4. The client is not at high risk for

65. A nurse administered RhoGAM to a client whose blood type is A (positive). Which of the following responses would the nurse expect to see? 1. Fever, flank pain, elevated bilirubin. 2. Induration and redness at the injection site. 3. Mild pain and swelling at the injection site. 4. Polycythemia, headache, hives.

65. 1. The nurse would expect to see fever, flank pain, and elevated bilirubin levels. 2. If the client were Rh (negative), the nurse would expect to see induration and redness at the injection site. 3. If the client were Rh (negative), the nurse would expect to see mild pain and swelling at the injection site. 4. The nurse would expect to see a hemolytic response, not polycythemia.

70. A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following laboratory values indicates that the medication is effective? 1. PT (prothrombin time): 12 sec (normal is 10-13 seconds). 2. INR (international normalized ratio): 2.5 (normal is 1.0-1.4). 3. Hematocrit 55%. 4. Hemoglobin 10 g/dL.

70. 1. The PT is normal. For someone taking warfarin, the PT time should be prolonged 1.5 to 2.0 times normal. 2. The INR should be between 2 and 3. 3. The hematocrit is elevated. It should be within normal limits.

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.

70. 1. The apical pulse need not be assessed be fore Methergine is administered. 2. The vaginal discharge need not be assessed before Methergine is administered. ####3. The blood pressure should be assessed before administering Methergine. 4. The episiotomy need not be assessed be fore Methergine is administered.

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.

78. 1. Although this is an important goal, it is not the most important. 2. Although this is an important goal, it is not the most important. ####3. This is the most important goal during the immediate postdelivery period. 4. Although this is an important goal, it is not the most important.

79. A woman is receiving Paxil (paroxetine) for postpartum depression. In order to prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following? 1. Alcohol. 2. Grapefruit. 3. Milk. 4. Cabbage.

79. 1. Clients should be warned about consuming alcohol when taking Paxil. 2. Grapefruit is not contraindicated for clients who have been prescribed Paxil. 3. Milk is not contraindicated for clients who have been prescribed Paxil. 4. Cabbage is not contraindicated for clients who have been prescribed Paxil.

A client is receiving an IV heparin drip at 16 mL/hr via an infusion pump for a diagnosis of deep vein thrombosis. The label on the liter bag of D5W indicates 50,000 units of heparin have been added. How many units of heparin is the client receiving per hour? __________ units per hour.

800 units/hour

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.

81. 1. Although the weight does drop precipi tously when the baby is born, this is not the primary reason for the client's cardio vascular compromise. ####2. This response is true. Once the pla centa is birthed, the reservoir for the mother's large blood volume is gone. 3. This response is not accurate. The cervix begins to contract shortly after delivery and the lochial flow is not related to the cardiovascular compromise that affects all postpartum patients. 4. This is a false statement. Maternal blood pressure does not drop precipitously when the baby's head emerges.

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

85. 1. Cesarean section incisions do not rou tinely need to be irrigated. ####2. This is appropriate. The nurse should assess for all signs on the REEDA scale. 3. The incision is held together with su tures or staples. It is unnecessary to apply steristrips at this time. 4. It is inappropriate for the nurse to pal pate the suture line for weaknesses.

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.

*1. Early ambulation does help to prevent thrombophlebitis. 2. Oral fluid intake does not directly prevent thrombophlebitis. 3. Massaging of the legs is not helpful and, in some situations, can actually be harm ful. If there is a clot in one of a client's lower extremity blood vessels, it can be dislodged when the leg is vigorously massaged. 4. High-fiber foods will prevent constipation, not thrombophlebitis.

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.

*1. Fundal assessment is the priority nursing action. 2. Pain level assessment is important, but it is not the priority nursing action. 3. Performing pericare is important, but it is not the priority nursing action. 4. Breast assessment is important, but it is not the priority nursing action.

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client? 1. The woman should never be left alone with her infant. 2. Symptoms rarely last more than one week. 3. Clinical response to medications is usually poor. 4. The woman must have her vitals assessed every two days.

*1. It is essential that the client never be left alone with her baby. 2. The statement is untrue. There is no set time frame for the resolution of the symptoms of postpartum psychosis. 3. Clinical response to medications is usually quite good. 4. The client's vital signs need not be assessed frequently

A client, who had no prenatal care, delivers a 10 lb 10 oz-baby boy whose serum glucose result 1 hour after delivery was 20 mg/dL. Based on these data, which of the following tests should the mother have at her 6-week postpartum check up? 1. Glucose tolerance test. 2. Indirect Coombs' test. 3. Blood urea nitrogen (BUN). 4. Complete blood count (CBC).

*1. The client should have a glucose tolerance test done at about 6 weeks' postpartum. Women who give birth to hypoglycemic and/or macrosomic babies are at increased risk of developing type 2 diabetes. 2. There is no indication in the scenario of Rh incompatibility that would require that an indirect Coombs' test be done. 3. There is no indication in the scenario that this client has impaired kidney function and should have a BUN done. 4. There is no indication in the scenario that this client should have a CBC done. There is no indication of anemia or infection.

A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply. 1. Look up the client's blood type in the chart. 2. Check the client's arm bracelet. 3. Check the blood type on the infusion bag. 4. Obtain an infusion bag of dextrose and water. 5. Document the time the infusion begins.

*1. The nurse must check the client's blood type. *2. The nurse must check the client's name by checking the bracelet and asking the client her name. *3. The nurse must compare the client's blood type with the blood type on the infusion bag. 4. The nurse must obtain an infusion of normal saline, not dextrose and water. *5. The time the infusion begins and ends must be documented

Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order? 1. Postpartum clients are high risk for thrombus formation. 2. Post-cesarean clients are high risk for fluid volume deficit. 3. Postpartum clients are high risk for varicose vein development. 4. Post-cesarean clients are high risk for poor milk ejection reflex.

*1. This rationale is correct. Because of an elevation in clotting factors, all postpartum clients are at high risk for thrombus formation. 2. The positive pressure boots improve blood return to the heart by preventing pooling of blood in the extremities. They are not applied to treat hypovolemia. 3. The rationale for the use of positive pressure boots is not related to varicose vein development. Varicose veins would, however, increase a client's potential for developing deep vein thrombosis. 4. The rationale for the use of positive pressure boots has nothing to do with a client's milk ejection reflex.

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.

1. Nourishment is a need of the client in the taking in phase. 2. Rest is a need of the client in the taking in phase. 3. Assistance with self-care is a need of the client in the taking in phase. *4. Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby.

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.

1. Clients in the taking in phase are not receptive to teaching. *2. During the taking in phase, clients need to internalize their labor experiences. Discussing the labor process is appropriate for this postpartum phase. 3. Clients in the taking in phase do not focus on future issues or needs. 4. Clients in the taking in phase are not receptive to teaching.

A client is 3-days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective? 1. The client has had no seizures since delivery. 2. The client's blood pressure has dropped from 160/120 to 130/90. 3. The client's postoperative weight has dropped from 154 to 144 lb. 4. The client states that her headache is gone.

1. Hydralazine is administered as an antihypertensive, not specifically as an antiseizure medication. Magnesium sulfate is the drug administered as an anticonvulsant to women with eclampsia. *2. Hydralazine is an antihypertensive. The change in blood pressure indicates that the medication is effective. 3. The weight loss is secondary to fluid loss. 4. The hydralazine is not administered to treat a headache.

A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6ºF, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority? 1. Ineffective breastfeeding. 2. Infection. 3. Ineffective individual coping. 4. Pain.

1. Infection, not ineffective breastfeeding, is the priority nursing diagnosis. *2. Infection is the priority nursing diagnosis. A temperature of 104.6ºF, as well as the client's other signs/symptoms, should immediately suggest the presence of infection. 3. Infection, not ineffective individual coping, is the priority nursing diagnosis. 4. Infection, not pain, is the priority nursing diagnosis.

A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority? 1. Lochia is serosa. 2. Client cries throughout the visit. 3. Nipples are cracked. 4. Client yells at the baby for crying.

1. Lochia serosa at 2 weeks' postpartum is unusual, but it does not put the client or her baby in imminent danger. 2. This client is exhibiting signs of postpartum depression. This is a problem that must be remedied, but it does not put the client or her baby in imminent danger. 3. The client's cracked nipples do need intervention, but they do not put the client or her baby in imminent danger. *4. The client is exhibiting inappropriate behavior when she yells at the baby for crying. The nurse must make additional assessments to determine whether there is any other evidence of abuse or neglect.

A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? 1. G1P0000, delivery at 29 weeks' gestation. 2. G2P1001, prolonged first stage of labor. 3. G2P0010, delivery by cesarean section. 4. G3P0200, delivery of 2200-gram neonate.

1. Preterm labor clients are not especially at high risk for postpartum hemorrhage. *2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH). 3. Cesarean section clients are not especially at high risk for PPH. 4. Clients who deliver small babies are not especially at high risk for PPH.

A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first? 1. Give two breaths. 2. Discontinue medications. 3. Call a code. 4. Check carotid pulse.

1. The nurse should call a code before beginning rescue breathing. 2. The nurse should call a code first and then discontinue the medication. *3. The nurse should call a code first. 4. The nurse should call a code before checking the carotid pulse.

64. A postoperative cesarean client, who was diagnosed with severe preeclampsia in labor and delivery, is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question? 1. Methergine (methylergonovine). 2. Magnesium sulfate. 3. Advil (ibuprofen). 4. Morphine sulfate.

64. 1. Methergine is contraindicated for this client. 2. Magnesium sulfate is the drug of choice for the treatment of severe preeclampsia. 3. Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID). It is an appropriate medication for the treatment of postpartum cramping. It is not contraindicated for this client. 4. Morphine sulfate is a narcotic analgesic. It is an appropriate medication for the treatment of postsurgical pain. It is not contraindicated for this client.

66. A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time? 1. Tell the father that his behavior is inappropriate. 2. Sit with the family and quietly communicate sorrow at their loss. 3. Help the couple to understand that their daughter is acting inappropriately. 4. Encourage the couple to send their daughter to her grandparents.

66. 1. This father is grieving. His anger is appropriate at this time. 2. This action is appropriate. The nurse is acknowledging that every member of the family is grieving the loss. 3. Five-year-old children do not understand death. They do respond to their parents' unusual behaviors. 4. Even though it is very difficult for the parents to deal with their own grief while caring for their daughter, the young girl may feel abandoned if sent unexpectedly to her grandparents.

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.

67. 1. This is inappropriate. Pork products are prohibited foods for Muslims. 2. This is inappropriate. Pork products are prohibited foods for Muslims. 3. This is inappropriate. Pork products are prohibited foods for Muslims. ####4. Although this is not a traditional Muslim dish, the foods are allowable by Muslim tradition.

68. A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding? 1. The mother states, "I'm so tired. Please feed the baby in the nursery for me." 2. The mother states, "Her eyes look like mine, but her chin is her Dad's." 3. The mother says, "We have decided to name her Sarah after my mother." 4. The mother says, "I breastfed her. I still need help swaddling her, though."

68. 1. This statement by the mother may be a true statement, but it may communicate the mother's difficulty with accepting her baby. 2. This statement is an example of positive maternal bonding. 3. This statement is an example of positive maternal bonding. 4. This statement is an example of positive maternal bonding.

69. A client who has been diagnosed with deep vein thrombosis has been ordered to receive 12 units heparin/min. The nurse receives a 500-mL bag of D5W with 20,000 units of heparin added from the pharmacy. At what rate in mL/hr should the nurse set the infusion pump? __________mL/hr.

69. 18 mL/hour

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.

72. 1. The client should not develop a headache from Methergine. 2. The client should not become nauseated from Methergine. ####3. Cramping is an expected outcome of the administration of Methergine. 4. The client should not become fatigued from Methergine.

83. A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby's and mother's infection? 1. Staphylococcus aureus. 2. Streptococcus pneumonia. 3. Escherichia coli. 4. Candida albicans.

83. 1. Staphylococcus aureus is the most common bacteria to cause mastitis. 2. Streptococcus pneumoniae is a major cause of pneumonia. 3. Certain strains of Escherichia coli cause severe gastritis. 4. The baby and mother are infected

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. 2. This answer is inappropriate. The client had an indwelling catheter inserted for the surgery. And even if the catheter were removed immediately after the op eration, she is paralyzed from the spinal anesthesia and unable to void. 3. This answer is inappropriate. The client has had major surgery. She will be con suming clear fluids, at the most, immedi ately after the cesarean section. 4. This answer is inappropriate. Immedi ately after surgery, the incision is covered by a dressing. Plus, it is too early for an infection to have appeared.

85. A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

85. 1. Serial grip strengths can be performed to monitor a client for magnesium sulfate toxicity. 2. Kernig's assessment is performed when checking for nuchal rigidity in a client with meningitis. 3. Pupillary responses are performed when a client has had a head injury or is not responsive. 4. Apical heart rate checks are performed when a client has a cardiac disease or is receiving digoxin.

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. 2. The postpartum assessment does not in clude carotid auscultation. ####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.

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.

87. 1. The nurse would not perform this action when performing Homan's sign. ####2. The nurse would dorsiflex the feet when performing Homan's sign. 3. The nurse would not palpate the calf and ankles when performing Homan's sign. 4. The nurse would not monitor the color of the extremities when performing Homan's sign.

Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

*1. The client would be expected to complain of pain. 2. The nurse would not expect to see bleeding. 3. The nurse would not expect to note warmth. 4. The nurse would not expect to see redness.

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

0.6 mL

A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

*1. Foul-smelling lochia is a sign of endometritis. 2. The nurse can assist the client with actions to relieve breast engorgement. 3. The nurse can assist the client with actions to relieve cracked nipples. 4. The nurse can assist the client with actions to relieve hemorrhoid pain.

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. 2. Massaging of the breast will stimulate more milk production. That is not the best action to take. 3. It is unnecessary to culture the breast. This client is engorged; she does not have an infection. 4. It is unnecessary to assess this client's temperature and pulse rate. This client is engorged; she is not infected.

A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful? 1. The mother's nipples are soft to the touch. 2. The baby swallows after every 5th suck. 3. The baby's pre- and postfeed weight change is 20 milliliters. 4. The mother squeezes her nipples during manual expression.

*1. If the woman has manually removed milk from her breasts, her nipples will soften to the touch. 2. If the baby is latched well, he should swallow after every suck. 3. The nurse would expect the baby to transfer 60 mL or more at the feeding. 4. The mother should not squeeze her nipple. The area behind the areola should be gently compressed

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

*1. It is appropriate to apply an ice pack to the area. 2. The sitz bath is an appropriate intervention beginning on the second postpartum day, not 2 hours after delivery. Sitz baths are usually performed 2 to 3 times a day. 3. It is not necessary for the client to sit on a pillow. 4. It is unnecessary for the client to be advised to put nothing in her rectum. Second-degree lacerations do not reach the rectum.

A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following PRN medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Demerol (meperidine). 3. Seconal (secobarbital). 4. Benadryl (diphenhydramine).

*1. Reglan is an antiemetic. It is the drug of choice for a client who is vomiting after surgery. 2. Demerol is a narcotic analgesic. It is not the appropriate medication for this client. 3. Seconal is a sedative. It is not the appropriate medication for this client. 4. Benadryl is an antihistamine. It is not the appropriate medication for this client.

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.

*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. 3. Oxytocin will have no affect on the hemorrhoids. 4. It is impossible to tell whether or not the hemorrhoids will change with subsequent pregnancies. *5. Topical anesthetics can provide relief from the discomfort of hemorrhoids.

Immediately after delivery, a woman is shaking uncontrollably. Which of the following 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.

*1. The appropriate action is to provide the client with warm blankets. 2. Postpartum shaking is very common. It is unnecessary to place the client in the Trendelenburg position. 3. Postpartum shaking is very common. It is unnecessary to notify the client's health care provider. 4. Postpartum shaking is very common. It is unnecessary to increase the client's intravenous fluid rate.

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. Engorgement will not be relieved by applying lanolin to the breasts. And the act of applying the lanolin may actually stimulate milk production. 3. If the woman expresses milk from her breasts, she will stimulate the breasts to produce more milk. 4. The Food and Drug Administration (FDA) recommends that milk suppressants not be administered because of the serious side effects of the medications.

The nurse is circulating on a cesarean delivery of a G5P4004. All of the client's previous children were delivered via cesarean section. The physician declares after delivering the placenta that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2000 mL. 2. Blood pressure of 160/110. 3. Jaundice skin color. 4. Shortened prothrombin time.

*1. The client with a placenta accreta is high risk for a large blood loss. 2. Placenta accreta is not related to a hypertensive state. 3. Placenta accreta is not related to the development of jaundice. 4. The nurse would not expect to detect a shortened prothrombin time when a client has a placenta accreta.

The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication? 1. Inhibit the mother's active immune response. 2. Aggressively destroy the Rh antibodies produced by the mother. 3. Prevent fetal cells from migrating throughout the mother's circulation. 4. Change the maternal blood type to Rh positive.

*1. The goal of the injection of RhoGAM is to inhibit the mother's immune response. 2. Immune globulin is composed of antibodies. When a client receives RhoGAM, she receives passive antibodies to inhibit her immune response. 3. Passive antibodies cannot prevent the migration of fetal cells throughout the mother's bloodstream. 4. A client's blood type is determined by her DNA. RhoGAM cannot change a client's DNA.

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.

*1. This action is appropriate. This client's respiratory rate is below normal. 2. A complaint of thirst is within normal. There is no need to notify the physician. 3. This urinary output is normal for a post partum client. There is no need to notify the physician. 4. Clients who have received epidurals will have numbness of their feet and ankles until the medication has metabolized. There is no need to notify the physician.

The obstetrician has ordered that a post-op cesarean section client's patient controlled 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.

*1. This answer is correct. Because the medication in a PCA pump is controlled by law, the medication must be wasted in the presence of another nurse. 2. This answer is inappropriate. A pain level of 0 is unrealistic after abdominal surgery. The nurse, however, should request that the doctor order one of the many oral analgesics to control the woman's discomfort. 3. This answer is inappropriate. The nurse should discontinue the medication as soon as he or she has received the order. 4. This answer is inappropriate. Once the intravenous has been punctured and used for one client, the bag cannot be reused.

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."

*1. This comment is inappropriate. It does not acknowledge the client's likely disappointment about having to have a cesarean section. 2. This comment conveys sensitivity and understanding to the client. 3. This comment may be true, but it does not acknowledge the client's likely disappointment about having to have a cesarean section. 4. This comment may be true, but it does not acknowledge the client's likely disappointment about having to have a cesarean section.

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.

*1. This response is correct. Reassuring the client is appropriate. 2. It is unlikely that the client has a urinary tract infection. 3. The urine will be blood-tinged from the lochia. 4. This question is unnecessary. It is unlikely that the client has a urinary tract infection.

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

*1. This response is correct. The couple is encouraged to wait until after involution is complete. 2. Although some clients do begin having intercourse once the episiotomy is healed and lochia stops, it is recommended that clients wait the full 6 weeks. 3. The couple is encouraged to wait until after involution is complete. 4. The couple is encouraged to wait until after involution is complete.

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. 2. This statement is incorrect. The immune systems of women during their pregnancies and immediately postpartum are slightly depressed. 3. This statement is incorrect. The baby will be susceptible to rubella whether or not the woman receives the vaccine. 4. In general, insurance companies will pay for vaccinations whenever they are needed

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. 2. This is unnecessary. There is no risk to the baby whether the mother is bottle feeding or breastfeeding. 3. This statement is incorrect. There is no risk to the baby. 4. This statement is incorrect. Because the mother has never had rubella, no passive antibodies to rubella crossed the placenta.

A client just delivered the placenta pictured below. The nurse will document that the woman delivered which of following placentas? 1. Circumvallate placenta. 2. Succenturiate placenta. 3. Placenta with velamentous insertion. 4. Battledore placenta.

1. A circumvallate placenta is a placenta with an inner ring created by a fold in the chorion and amnion. Clients with this type of placenta are at high risk for antepartal complications like preterm labor. 2. A succenturiate placenta is characterized by one primary placenta that is attached via blood vessels to satellite lobe(s). Clients with this type of placenta are at high risk for postpartum hemorrhage. 3. A placenta with a vellamentous insertion has an umbilical cord that is formed a distance from the placenta. Since the vessels are unsupported between the placenta and the cord, hemorrhage may result if one or more of the vessels tears. *4. The battledore placenta is characterized by an umbilical cord that is inserted on the periphery of the placenta. Clients with this type of placenta are at high risk for preterm problems like preterm labor and hemorrhage.

A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus? 1. Abdominal striae. 2. Oliguria. 3. Omphalocele. 4. Absent bowel sounds.

1. Abdominal striae are stretch marks. They are a normal side effect of pregnancy. 2. Oliguria is a complication that may develop after surgery, but it is not a symptom of paralytic ileus. 3. An omphalocele is a herniation of the intestines into the umbilical cord. It is sometimes seen in newborns. *4. An absence of bowel sounds may indicate that a client has a paralytic ileus.

A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform? 1. Cover the wound with sterile wet dressings. 2. Notify the surgeon. 3. Elevate the head of the client's bed slightly. 4. Flex the client's knees.

1. After the surgeon is notified, the nurse should stay with the patient while another staff member gathers supplies, including a suture removal kit and personal protective equipment as well as sterile saline solution and a large syringe. *2. The highest priority action is to notify the surgeon. 3. The nurse should elevate the client's bed slightly. 4. The nurse should flex the client's knees slightly.

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.

1. Although breastfeeding does have a protective effect on postpartum blood loss, involution can take up to 6 weeks in breastfeeding women as well as bottle feeding women. *2. There is evidence to show that women who breastfeed their babies are less likely to develop type 2 diabetes later in life 3. Women who breastfeed have not been shown to have higher levels of bone density later in life. 4. Babies whose mothers breastfeed are less likely to develop infections than are bottlefed babies. The mothers, however, have not been shown to have the same protection.

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

1. It is unlikely that the woman is febrile. 2. The woman should maintain an adequate fluid intake. *3. Diaphoresis is normal during the postpartum period. 4. There is no need to report the diaphoresis to the baby's pediatrician.

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.

1. Although the client is showing signs of positive bonding, she definitely needs a great deal of teaching. *2. This response is correct. The client is showing signs of positive bonding—enface positioning and stroking of the baby's cheeks—and is in need of information on child care. 3. This action is absolutely inappropriate at this time. There are no signs of poor bonding or of abuse. 4. There are no signs of poor bonding.

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.

1. An assessment of the woman's pulse rate is important, but it is not the most important assessment. *2. An assessment of the woman's fundus is the most important assessment to perform on this client. 3. An assessment of the woman's bladder is important, but it is not the most important assessment. 4. An assessment of the woman's breasts is important, but is not the most important assessment.

A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediolateral episiotomy. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain.

1. Because the baby has Down syndrome, this is an appropriate nursing diagnosis, but it is not the highest priority diagnosis. *2. This is the priority nursing diagnosis. Because the baby is macrosomic, the client is high risk for uterine atony that could lead to heavy vaginal bleeding possibly resulting in fluid volume deficit. 3. Although the client is at high risk for infection, it is not highest priority. Infections take time to develop and this client is only 10 minutes postdelivery. 4. Although the client is at high risk for pain, especially from the episiotomy, this is not the highest priority nursing diagnosis.

A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery while the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for? 1. Pruritus. 2. Nausea. 3. Postural headache. 4. Respiratory depression.

1. Both the spinal anesthesia and the epidural anesthesia client are at high risk for developing pruritus. 2. Both the spinal anesthesia and the epidural anesthesia client are at high risk for developing nausea. *3. The client who has had the spinal anesthesia is much more likely to develop a postural headache than a client who had epidural anesthesia. 4. Both the spinal anesthesia and the epidural anesthesia client are at high risk for developing respiratory depression.

The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching in the hospital was successful? 1. The client is breastfeeding her baby every two hours. 2. The client is using a diaphragm for family planning. 3. The client is taking her temperature every morning. 4. The client is seeking care for a recent weight loss.

1. Breastfeeding is contraindicated when a mother is HIV positive. 2. It is recommended that HIV-positive clients use condoms for family planning. 3. It is unnecessary to take her temperature every morning. If she should develop a fever, she should seek medical assistance as soon as possible, however. *4. The client should seek care for a recent weight loss. This may be a symptom of full-blown AIDS.

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.

1. Celery is especially high in vitamin K, but it contains very little iron or vitamin A. Cream cheese is very high in fat. 2. Yogurt is high in calcium but is not high in either iron or vitamin A. Bananas are high in vitamin B6, potassium, and vitamin C, but they are not high in either iron or vitamin A. 3. Strawberries are very high in vitamin C, but they are not high in either iron or vitamin A. *4. Broccoli is very high in vitamin A and also contains iron.

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.

1. Clients are not recommended to pump their breasts after feedings unless there is a specific reason to do so. *2. This statement is true. The best way to prevent engorgement is to feed the baby every 2 to 3 hours. 3. Clients should not restrict babies' feeding times. Babies feed at different rates. Babies themselves, therefore, should regulate the amount of time they need to complete their feeds. 4. Clients are not recommended to supplement with formula unless there is a specific reason to do so.

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.

1. Episiotomy sutures are not removed. 2. Clients who have had episiotomies may or may not require pain medication. The medicine should be offered throughout the day since it is usually ordered prn. *3. This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the suture line. 4. It is not recommended to irrigate episiotomy incisions.

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.

1. It is unlikely that this client needs to be catheterized. 2. It is unnecessary to measure this client's output. *3. This response is correct. Polyuria is normal. 4. It is unnecessary to do a specific gravity on the client's output.

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."

1. Even though this response may be true, the client's feelings are being ignored by the nurse. 2. This response is inappropriate. Even though the baby is well, the client feels disappointed with her performance. 3. Even though this response may be true, the client's feelings are being ignored by the nurse. *4. This response shows that the nurse has an understanding of the client's feelings.

The nurse should expect to observe which behavior in a 3-week multigravid postpartum client with postpartum depression? 1. Feelings of infanticide. 2. Difficulty with breastfeeding latch. 3. Feelings of failure as a mother. 4. Concerns about sibling jealousy.

1. Feelings of infanticide are not consistent with the diagnosis of postpartum depression. 2. Difficulty latching babies to the breast is an independent problem from postpartum depression. Some mothers with depression are successful breast feeders, while some mothers who do not experience depression have difficulty latching their babies to the breast. *3. Mothers who experience postpartum depression often do feel like failures. 4. Concerns about sibling rivalry are not related to postpartum depression.

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.

1. Fundal height is measured using a centimeter tape during pregnancy, not in the postpartum period. *2. The nurse should stabilize the base of the uterus with his or her dependent hand. 3. The fundus should be palpated using the flat surface of the fingers. 4. No vaginal examination should be per formed by the nurse.

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.

1. Heavy lochia is not a normal finding. Moderate lochia, which is similar in quantity to a heavy menstrual period, is a normal finding. 2. The woman's fundus is firm. There is no need to massage the fundus. 3. The fundus is at the umbilicus and it is firm. It is unlikely that her bladder is full. *4. Because of the heavy lochia, the nurse should notify the woman's health care provider.

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.

1. It is inappropriate to advise a breastfeeding mother to switch to the bottle unless there is a specific medical reason for her to do so. 2. Massaging the fundus will not relieve the client's discomfort. 3. An alternate position will not relieve the client's discomfort. *4. The nurse should discuss the action of oxytocin.

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."

1. It is not recommended that breastfeeding mothers go on weight-reduction diets. In addition, it is not necessary for mothers to drink milk in order to make breast milk. 2. When a breastfeeding woman has a poor diet, the quality of her breast milk changes very little. Rather if a mother consumes a poor diet, it is her own body that will suffer. 3. Mothers do not need to eat 3000 calories a day while breastfeeding. *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.

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."

1. It is not unusual for post-cesarean section clients to have had no bowel movements. The client should be advised to drink flu ids and to ambulate to stimulate peristalsis. 2. This response is inappropriate. This client is obviously very concerned about her bowel pattern. 3. This response is inaccurate. Clients who have received antibiotics often complain of diarrhea as a result of the change in their intestinal flora. *4. Consuming fluids and fiber and exercising all help clients to reestablish normal bowel function.

A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104. 2. Urinary output 240 cc/12 hr. 3. Blood pressure 160/120. 4. Temperature 100ºF.

1. It is unlikely that an apical heart rate of 104 is responsible for the client's changes. *2. The urinary output is the likely cause of the client's changes. 3. It is unlikely that a blood pressure of 160/120 is responsible for the client's changes. 4. It is unlikely that a temperature of 100ºF is responsible of the client's changes.

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.

1. It is unnecessary for a bottlefeeding mother to increase her fluid intake. 2. It is inadvisable for a bottlefeeding mother to massage her breasts. 3. It is inadvisable for a bottlefeeding mother to apply heat to her breasts. *4. The mother should be advised to wear a supportive bra 24 hours a day for a week or so.

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.

1. It is unnecessary to apply antibiotic ointment to the perineum after delivery. *2. Clients should be advised to change their pads at each voiding. 3. The clients should void about every 2 hours, but this action is not an infection control measure. 4. It is unnecessary to spray the perineum with a povidone-iodine solution. Plain water, however, should be sprayed on the perineum.

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.

1. Milk inhibits the absorption of iron. Milk and iron should not be consumed at the same time. 2. There is no recommendation that iron be taken with ginger ale. *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. 4. There is no recommendation that iron be taken with chamomile tea.

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.

1. Nipple shields should be used sparingly. Other interventions should be tried first. 2. Soap will deplete the breast of its natural lanolin. It is recommended that women wash their breasts with warm water only while breastfeeding. *3. Rotating positions at feedings is one action that can help to minimize the severity of sore nipples. 4. It is inappropriate to recommend that the woman switch to formula at this time.

The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement? 1. Maintain client in left lateral recumbent position. 2. Teach sitz bath use on second postoperative day. 3. Perform active range of motion exercises until ambulating. 4. Assess central venous pressure during first postoperative day.

1. Postoperative C/section clients should turn every 2 hours to prevent stasis of their lung fields. 2. Sitz baths are rarely ordered for C/section clients. *3. Active range of motion exercises will help to prevent thrombus formation in C/section patients. 4. Central venous pressure is rarely assessed in C/section clients.

The nurse should suspect puerperal infection when a client exhibits which of the following? 1. Temperature of 100.2ºF. 2. White blood cell count of 14,500 cells/mm3. 3. Diaphoresis during the night. 4. Malodorous lochial discharge.

1. Puerperal infection is defined as a temperature of 100.4˚F or higher after 24 hours' postpartum. 2. Although clients who develop endometritis will have significantly elevated white cell counts, a WBC count of 14,500 is normal for a postpartum client. 3. Clients who develop infections may perspire profusely. However, diaphoresis is normally seen in postpartum clients, and is not in itself indicative of postpartum infection. *4. A malodorous lochial flow is a common sign of a puerperal infection.

The nurse is discharging four Rh-negative clients from the maternity unit. The nurse knows that further teaching is needed when the client who had which of the following deliveries asks why she has not received her RhoGAM? 1. Abortion at 10 weeks' gestation. 2. Fetal demise at 24 weeks' gestation. 3. Birth of Rh-negative twins at 35 weeks' gestation. 4. Delivery of a 40-week-gestation Rh-positive baby.

1. The client should receive a RhoGAM injection after a spontaneous abortion. 2. The client should receive a RhoGAM injection after a fetal demise. *3. The client does not need a RhoGAM injection after the delivery of Rhnegative twins. 4. The client should receive a RhoGAM injection after birth of an Rh-positive baby.

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.

1. The fundus should have descended below the umbilicus and there is no such lochia as "lochia rosa." 2. The fundus should have descended below the umbilicus and the lochia does not turn to alba until about 10 days postpartum. 3. The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3. *4. The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3.

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.

1. The involution is normal. 2. The involution is normal and the lochia is rubra. *3. This response is correct. The involution is normal and the lochia is rubra. 4. The lochia is moderate rubra.

A rubella nonimmune, breastfeeding client has just received the rubella vaccine. Which of the following side effects should the nurse warn the client about? 1. The baby may develop a rash a week after the shot. 2. The baby may temporarily reject the breast milk. 3. The mother's milk supply may decrease precipitously. 4. The mother's joints may become painful and stiff.

1. The mother, not the baby, may develop a macular rash a week after the shot. The baby will be unaffected. 2. There is no evidence to suggest that babies whose mothers have received the rubella vaccine reject their mother's breast milk. 3. There is no evidence to suggest that the mother's breast milk supply will drop. *4. One out of 4 women complains of painful and stiff joints after receiving the injection.

A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period? 1. Infection. 2. Bloody urine. 3. Heavy lochia. 4. Rectal abrasions.

1. The nurse should monitor the client for signs of infection after the first 24 hours have past. 2. The client is not at high risk for bloody urine. *3. The client should be monitored carefully for heavy lochia. 4. The client is not at high risk for rectal

On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was assessed 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%.

1. The nurse would not expect the values to rise. These results may indicate that the client is dehydrated or third spacing fluids (i.e., fluid is shifting into her interstitial spaces). 2. The nurse would not expect the values to remain the same. On average, clients lose about 500 cc of blood during spontaneous vaginal deliveries. *3. The nurse would expect these values—a slight decrease in both hemoglobin and hematocrit values. 4. The nurse would not expect the values to drop to these levels.

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.

1. The nurse would not expect to see any drainage. *2. The nurse would expect to see well approximated edges. 3. The nurse would not expect to see ecchymosis. 4. The nurse would not expect to see redness.

A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? 1. Engorgement. 2. Mastitis. 3. Blocked milk duct. 4. Low milk supply.

1. The nurse would not expect to see engorgement. 2. The nurse would not expect to see mastitis. 3. The nurse would not expect to see a blocked milk duct. *4. The nurse would expect that the woman would have a low milk supply. administered to raise the level in the client's blood stream. The medication, which is an anticonvulsant, is being administered to prevent further seizures. The potassium level, however, is well below normal.

A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6˚F, P 72, R 20, BP 150/100, and her reflexes are 4. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes.

1. The results are not normal. This client's blood pressure is markedly elevated and the client is hyperreflexic. *2. The nurse should notify the physician of the signs of preeclampsia. 3. There is no need to discontinue the intravenous infusion. 4. The findings are consistent with signs of preeclampsia. It would be inappropriate to wait fifteen minutes to verify the results.

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.

1. The urinary output increases during the early postpartum period. 2. The blood pressure should remain stable during the postpartum. *3. The blood volume does drop precipitously during the early postpartum period.

The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? 1. Massage the uterus. 2. Notify the obstetrician. 3. Administer an oxytocic as ordered. 4. Assist the client to the bathroom.

1. The uterus is contracted. Massaging the uterus will not remedy the problem of heavy lochial flow. *2. It is important for the nurse to notify the physician. The client is bleeding more than she should after the delivery. 3. An oxytocic promotes contraction of the uterine muscle. The muscle is already contracted. 4. The uterus is at the umbilicus. It is unlikely that it is displaced from a full bladder.

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

1. The white blood cell count is within normal limits for a postpartum client. 2. The red blood cell count is within normal limits for a postpartum client. *3. The client's hematocrit is well below normal. This value should be reported to the client's health care provider. 4. The hemoglobin is within normal limits for a postpartum client.

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

1. The woman is not exhibiting symptoms of galactorrhea, which occurs when a woman produces breast milk even though she has not delivered a baby. *2. This is true. Oxytocin stimulates sexual orgasms and is also the hormone that stimulates the milk ejection reflex. 3. This is incorrect. Galactosemia is a genetic disease. Babies who have the disease are unable to digest galactose, the predominant sugar in breast milk. 4. This is an unlikely explanation of the problem.

The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time? 1. Advise the woman to wash the area with soap to prevent mastitis. 2. Provide the woman with a tube of topical lanolin. 3. Remind the woman that the baby can become sick if he drinks the blood. 4. Get the woman an order for a topical anesthetic.

1. The woman should not wash with soap. Soaps destroy the natural lanolins produced by the body. *2. A small amount of lanolin should be applied to the nipple after each feeding. 3. The baby will not become sick from the blood. The woman should be warned that he may spit up digested and/or undigested blood after the feeding, however. 4. Topical anesthetics are not used on the breasts. The woman could receive an oral analgesic, however.

In which of the following situations should a nurse report a possible deep vein thrombosis (DVT) even when the woman has a negative Homan's sign? 1. The woman complains of numbness in the toes and heel of one foot. 2. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. 3. One of the woman's calves is swollen, red, and warm to the touch. 4. The veins in the ankle of one of the woman's legs are spider-like and purple.

1. These findings are not consistent with a diagnosis of DVT. They may be due to a resolving epidural anesthesia. 2. These findings are normal. Many women complain of leg cramping. *3. Even with a negative Homan's sign, these findings—swelling, redness, and warmth—indicate presence of a DVT. 4. These findings are normal. Many women develop spider veins during their pregnancies.

A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client? 1. Strongly advise the client to breastfeed her baby. 2. Perform hourly incentive spirometer respiratory assessments. 3. Suggest that the nursery nurse feed the baby in the nursery. 4. Provide the client with supervised instruction on baby care skills.

1. This action is inappropriate. Breastfeeding is contraindicated when the mother uses illicit drugs. 2. This action is unnecessary. There is nothing in the scenario that implies that the client is having respiratory difficulties. 3. This action is inappropriate. Rather the nurse should encourage mother/baby interaction and provide the mother with parenting education. *4. Providing instruction on baby care skills is a very important action for the nurse to perform.

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 deviated 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.

1. This action may be needed, but it is not the first action that should be taken. *2. This action is the first that the nurse should take. 3. This action may be needed, but it is not the first action that should be taken. 4. This action is needed, but it is not the first action that should be taken.

A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time.

1. This blood pressure shows that no adverse side effects have resulted from the administration of the medication. One side effect of the medication is an elevation in blood pressure. 2. Pulse rate is unrelated to the administration of the medication. *3. The fundal response indicates that the medication was effective in contracting the uterus. 4. The prothrombin time is unrelated to the administration of the medication.

A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action? 1. Postpartum hemorrhage. 2. Severe postural headache. 3. Pruritic skin rash. 4. Paralytic ileus.

1. This client in high-Fowler's position is no more at high risk for postpartum hemorrhage than a spinal anesthesia client who has been kept flat after surgery. *2. The nurse would expect the client to complain of a severe postural headache. 3. This client is no more at high risk for a pruritic rash than a spinal anesthesia client who has been kept flat after surgery. 4. This client is no more at high risk for paralytic ileus than a spinal anesthesia client who has been kept flat after surgery.

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."

1. This is an incorrect statement. *2. This statement is accurate. Mothers often do not feel bladder pressure after delivery. 3. Local anesthesia does not affect a client's ability to feel bladder distension. 4. This statement is inappropriate. The nurse should escort the woman to the bathroom to urinate.

The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby with visible defects. Which of the following actions by the nurse is appropriate? 1. Discourage the parents from naming the baby. 2. Advise the parents that the baby's defects would be too upsetting for them to see. 3. Transport the baby to the morgue as soon as possible. 4. Give the parents a lock of the baby's hair and a copy of the footprint sheet.

1. This is inappropriate. Naming the baby is a means of acknowledging both the existence and the death of the baby. 2. This is inappropriate. Client's imaginations of what the baby looks like are often much worse than the reality. 3. This is inappropriate. The couple should be provided time to be with their baby before transporting the baby to the morgue. *4. This is appropriate. The small mementos will provide the couple with something tangible to remember the pregnancy and baby by.

A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time? 1. "Monitor your blood glucose five times a day until your 6-week check-up." 2. "I will teach you how to inject insulin before you are discharged." 3. "Daily exercise will help to prevent you from becoming diabetic in the future." 4. "Your baby should be assessed every 6 months for signs of juvenile diabetes."

1. This is unnecessary. Gestational diabetic clients need not assess their blood glucose levels during the postpartum. 2. This is unnecessary. Gestational diabetic clients need not inject insulin during the postpartum. *3.. This is an appropriate statement to make. 4. This is not appropriate. Babies rarely develop diabetes before age 2. Plus, juvenile diabetes is now called type 1 diabetes.

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.

1. This is unnecessary. PCA pumps monitor the number of attempts patients make. *2. This information is correct. Clients often experience nausea and/or itching when PCA narcotics are administered. 3. This is a false statement. Family members should not press the button for the client. 4. This information is untrue. It is unnecessary for family members to inform the nurse. It is not unusual for clients to fall asleep when receiving PCA.

A woman, who wishes to breastfeed, advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate? 1. Advise the woman that unfortunately she will be unable to breastfeed. 2. Examine the woman's breasts to see where the incision was placed. 3. Monitor the baby's daily weights for excessive weight loss. 4. Inform the woman that reduction surgery rarely affects milk transfer

1. This may be true, but the mother may also be a successful breastfeeder. 2. This action can be helpful, but the placement of the incision will not necessarily determine the client's ability to breastfeed. *3. This action is very important. 4. This information is not accurate. Breast reduction surgery often does affect a woman's ability to breastfeed.

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."

1. This response is accurate, but the nurse is exhibiting a lack of caring. 2. This response is inappropriate. Even if the lung fields are clear, the client should perform respiratory exercises. 3. This response is inappropriate. Simply breathing deeply may not be as effective as coughing. *4. This is the appropriate response. The nurse is providing the client with a means of reducing the discomfort of postsurgical coughing.

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?"

1. This response is inappropriate. It is likely that as long as the woman breastfeeds she will experience vaginal dryness. 2. This is an inappropriate response. It is unlikely that a proliferation of Candida is the problem. *3. This response is correct. The woman should be encouraged to use a lubricating jelly or oil. 4. It is unlikely that the problem is related to the episiotomy repair.

A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 3. Ask the woman if she would like the doctor to prescribe a sedative for her. 4. Remove the baby from the delivery room as soon as possible.

1. This response is inappropriate. The client is not thinking about a future pregnancy at this time. *2. This response is correct. 3. This response is not appropriate. The nurse should ask the client if she would like to see or hold the baby. 4. This response is not appropriate. The nurse should ask the client if she would like to see or hold the baby.

A breastfeeding woman calls the pediatric nurse with the following complaint: "I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I give the baby until I get better?" Which of the following replies by the nurse is appropriate at this time? 1. "Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes." 2. "Don't forget to pump your breasts every 3 hours while you are feeding the baby the prescribed formula." 3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." 4. "In addition to feeding the baby formula, you should wear a surgical face mask when you are around him."

1. This response is inappropriate. The client should not be advised to switch to formula. 2. This response is inappropriate. The client should not be advised to switch to formula. *3. This response by the nurse is appropriate. 4. This response is inappropriate. The client should not be advised to switch to formula.

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.

1. This response is incorrect. Clients who have had spinal anesthesia are at high risk for spinal headaches when they are elevated soon after surgery. 2. It is unnecessary to report absent bowel sounds to the client's physician. *3. The woman should turn, cough, and deep breathe every 2 hours. 4. There is no indication in the scenario that this client needs patellar reflex assessments every 2 hours.

A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O (negative), the baby's type is A (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate? 1. Advise the client to keep her physician appointment at the end of the week in order to receive her RhoGAM injection. 2. Carefully check the record to make sure that the RhoGAM injection was administered. 3. Notify the client that because her baby's Coombs' test was negative she will not receive an injection of RhoGAM. 4. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.

1. This response is incorrect. RhoGAM must be administered within 72 hours of delivery. *2. This response is correct. The nurse should not finalize an Rh (negative) client's discharge until the client has received her RhoGAM injection. 3. This response is incorrect. A negative direct Coombs' test means that no maternal antibodies were detected in the baby's circulatory system. The nurse would expect to detect a negative direct Coombs' test. 4. This response is unacceptable. Rh-(negative) clients should receive their RhoGAM injection before 72 hours' postpartum or by discharge, whichever is earlier.

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 postpartum 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."

1. This response is not accurate. Clients can begin to perform some exercises during the postpartum period. 2. The client can begin Kegel exercises, and little by little she can add other muscle toning exercises during the postpartum period. 3. It is inappropriate to make this statement to a client. Her prepregnancy exercise schedule may be beyond her physical abilities at this time. *4. This statement is correct. The client should begin with Kegel exercises shortly after delivery, move to abdominal tightening exercises in the next couple of days, and then slowly progress to stomach crunches, and so on.

A bottlefeeding woman, 11⁄2 weeks postpartum from a vaginal delivery, calls the obstetric 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."

1. This response is not appropriate. This client is bleeding heavily and she is not breastfeeding. 2. It is unlikely that this client is menstruating since she is only 11⁄2 weeks postpartum. 3. This response is not appropriate. The client should not bleed heavily, especially so long after delivery. *4. This response is appropriate. The client should be examined to assess her involution.

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."

65. 1. This is not the best response by the nurse. 2. This is not the best response by the nurse. ####3. The nurse should forewarn the mother about the likelihood of the 2-year-old's jealousy. 4. This is not the best response by the nurse.

67. The nurse is caring for a client, G3P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make? 1. "Thank goodness. It could have been untreatable." 2. "I'm so happy that you have other children who are healthy." 3. "These things happen. They are the will of God." 4. "It is appropriate for you to cry at a time like this."

67. 1. This statement is inappropriate. Any defect is devastating for the parents to accept. 2. This statement is inappropriate. This child is affected. That is all that matters. 3. This statement is inappropriate. The nurse must not impose his or her beliefs on the couple. 4. This statement is appropriate. Clients may need help or permission to express their grief.

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. 2. This question is inappropriate. The Sev enth Day Adventist Sabbath is on Satur day, not on Sunday. 3. This question is inappropriate. Baptism in the Seventh Day Adventist tradition is performed after the child reaches the age of accountability. 4. This question is inappropriate. Rabbis are the leaders of people of the Jewish faith. And mohels, who are not neces sarily rabbis, perform ritual Jewish circumcisions.

71. The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen (hPL). 4. Human chorionic gonadotropin (hCG).

71. 1. The drop in estrogen is not related to the glucose level. 2. The drop in progesterone is not related to the glucose level. 3. The drop in human placental lactogen (hPL) is related to the glucose level. 4. The drop in human chorionic gonadotropin is not related to the glucose level.

73. A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take? Select all that apply. 1. Swaddle the baby in a baby blanket. 2. Discuss funeral options for the baby. 3. Encourage the couple to try to get pregnant again soon. 4. Ask the couple whether or not they would like to hold the baby. 5. Advise the couple that the baby's death was probably for the best.

73. 1, 2, and 4 are correct. 1. This is an appropriate action. The baby should be handled with respect. 2. This is an appropriate action. Funerals help clients to achieve closure and to provide others with a means of acknowledging the baby's death. 3. This is inappropriate. The couple must grieve the loss of this child. 4. This is an appropriate action. Although there are some clients who will decline to hold their babies, the action is very important for those who accept the opportunity. 5. This action is inappropriate. Stating that the loss of a baby is for the best is very demeaning and unfeeling.

74. A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following should be included in the patient teaching? 1. Only take ibuprofen for pain. 2. Avoid eating dark green leafy vegetables. 3. Drink grapefruit juice daily. 4. Report any decrease in urinary output.

74. 1. Ibuprofen is an NSAID. It can exacerbate the action of Coumadin. The client should be encouraged to take acetaminophen, if needed, for pain. 2. This action is correct. Dark green leafy vegetables contain vitamin K. The vitamin would decrease the anticoagulant affect of Coumadin. 3. The client should be advised to avoid drinking grapefruit juice. It may increase the action of Coumadin. 4. The client should be advised to report signs of internal bleeding, such as hematuria. Decreased urinary output would not be expected in a client taking Coumadin.

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. 2. The capsule should be taken with juice or food to minimize the bitter taste. 3. Headache is not a side effect of Colace. 4. The medication does not change the color of a client's urine.

75. A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman? CHAPTER 11 HIGH-RISK POSTPARTUM 377 1. Endometrial ischemia. 2. Postpartum hemorrhage. 3. Prolapsed uterus. 4. Vaginal hematoma.

75. 1. Endometrial ischemia is not a complication of a succenturiate placenta. 2. The nurse should carefully monitor this client for signs of postpartum hemorrhage. 4. The hemoglobin is below normal. It should be within normal limits.

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.

75. 1. This client's lochia flow and vital signs are normal. She is exhibiting no signs of fluid volume deficit. 2. This client has had no episiotomy or per ineal laceration. She is exhibiting no signs of impaired skin integrity. 3. This client is voiding as expected— approximately every 2 hours. She is exhibiting no signs of impaired urinary elimination. ####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.

76. Which of the following is a priority nursing diagnosis for a woman, G10P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration is comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role.

76. 1. This is an important nursing diagnosis, but it is not the priority diagnosis. 2. This is an important nursing diagnosis, but it is not the priority diagnosis. 3. Fluid volume deficit related to blood loss is the priority nursing diagnosis. 4. This is an important nursing diagnosis, but it is not the priority diagnosis

78. On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client? 1. "Have you ever had anesthesia before?" 2. "Do you have any allergies?" 3. "Do you scar easily?" 4. "Are there many stairs in your home?"

78. 1. This is an important question to ask the client but it is unrelated to her discharge needs. 2. This is an important question to ask the client but it is unrelated to her discharge needs. 3. This is an important question to ask the client but it is unrelated to her discharge needs. 4. The client has had major surgery. The client will need some assistance when she returns home, especially if she has a number of stairs to climb.

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.

79. 1. It is inappropriate for the nurse to dele gate this action. Physical assessment is a skill that requires professional nursing judgment. 2. It is inappropriate for the nurse to dele gate this action. Teaching is a skill that requires professional nursing knowledge. ####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. 4. It is inappropriate for the nurse to dele gate this action. The chart is a legal doc ument and documentation is a skill that requires professional nursing knowledge.

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.

80. 1. There is nothing in the scenario that in dicates that the client's feet and ankles need to be assessed. 2. This is unnecessary. The blood pressure can be assessed while a client is breast feeding. ####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. 4. It is unnecessary to measure the epi siotomy. It is sufficient to document the type of episiotomy that was performed.

81. A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible.

81. 1. This action is inappropriate. The woman should apply warm soaks to the breast. 2. The action is appropriate. The woman should breastfeed frequently. 3. The woman should be discouraged from weaning. 4. It is unnecessary for the client to notify the pediatrician. The baby's health is not in jeopardy.

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. 2. Discharge teaching should be initiated at the time of admission. This nurse is cor rect in initiating the process in the labor room. 3. Discharge teaching should be initiated at the time of admission. This nurse is cor rect in initiating the process in the labor room. 4. Discharge teaching should be initiated at the time of admission. This nurse is cor rect in initiating the process in the labor room.

82. A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 1. Breast implants often contaminate the milk with toxins. 2. The glandular tissue of women who need implants is often deficient. 3. Babies often have difficulty latching to the nipples of women with breast implants. 4. Women who have implants are often able exclusively to breastfeed.

82. 1. This response is incorrect. The implants usually do not leach toxins into the surrounding tissue. 2. The glandular tissue of most women who choose to have breast augmentation surgery is normal. 3. This information is incorrect. Implants usually do not affect a baby's ability to latch. 4. This information is true. Women who have had augmentation surgery usually are able to breastfeed exclusively.

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.

83. 1. This action is unsafe. It is unsafe to place anything in the vagina before involution is complete. 2. This response is inappropriate. The amount of discharge does not determine the type of pad that can be used. 3. This response is inappropriate. The client's pain does not determine the type of pad that can be used. ####4. This response is correct. It is unsafe to place anything in the vagina before involution is complete.

84. A client on the postpartum unit has been diagnosed with deep vein thrombosis. The following titration schedule is included in the client's orders: If INR is 1: administer 7500 units heparin subcutaneously (sc) If INR is 1.1 to 2: administer 5000 units heparin sc If INR is 2.1 to 3: administer 2500 units heparin sc If INR is 3: administer 0 units heparin sc The client's INR is 2.6. How many mL of heparin will the nurse administer if the available concentration of heparin is 5000 units per 0.2 mL? __________ mL.

84. 0.1 mL