Maternity exam 4
A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client?
Begin feeding on the less sore nipple.
The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which condition?
Bladder distention
A woman who is 6 cm dilated has the urge to push. The nurse would instruct the woman to:
Blow in short breaths during the contraction
When a hypotonic labor dysfunction occurs in a patient who is dilated to 5 cm with membranes intact, the nurse informs the patient that the physician most likely will:
Perform an amniotomy
A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate?
Prepare the client for surgery.
A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?
Prepare to administer oxygen at 8 to 10 L by tight face mask.
The nurse is monitoring a new mother for signs of postpartum depression. Which observations in the mother indicate the need for further data collection related to this form of depression? Select all that apply.
-Shows a lack of interest in eating -Lacks the ability to concentrate on tasks -Complains of feeling tired all of the time
The nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse should document which expected changes?
-Slowed pulse rate -Elevated blood pressure
The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which statement by the mother is most likely to occur at this time related to her birth experience?
"I do not feel any urges yet to empty my bladder."
A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement?
"I don't need birth control because I will be breastfeeding."
The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching?
"I should avoid wearing a bra at this time."
The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.
Rest during the acute phase. Wear a supportive, nonunderwire bra. Maintain a fluid intake of at least 3000 mL. Continue to breastfeed if the breasts are not too sore.
The nurse is reinforcing instructions to a client who had an episiotomy during the birthing process. Which statement by the client indicates a need for further teaching?
"I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115° F."
The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching?
"I will change the perineum pads three times a day."
The nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures?
"I will massage the breasts before feeding to stimulate let-down."
The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration?
"It will help prevent bleeding and control bleeding if it occurs."
A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. The nurse explains that giving a narcotic analgesic medication at this stage of labor will:
Results in respiratory depression to the newborn
The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching?
"My left breast is sore, so I will offer only my right breast frequently for breastfeeding."
The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions are included in the plan of care? Select all that apply.
-Maintaining bed rest -Elevating the affected extremity -Applying warm compresses to the affected area as prescribed
A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence? Select all that apply.
Retained placental fragments Maternal reproductive tract infections
A nurse instructs a womans labor coach to comfort her by firmly pressing on her lower back. This technique is called:
Sacral pressure
The nurse is providing nutritional counseling to a new mother who is breastfeeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount?
500 calories per day
A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate?
A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate?
After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make?
The bright red bleeding is abnormal and should be reported.
The nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery supports this diagnosis?
Abdominal tenderness and chills
The nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which signs/symptoms should the nurse expect to note when collecting data on the client? Select all that apply.
Absence of fetal movement Fetal heart tones not audible Prenatal record indicating no change in fundal height for several weeks
The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action?
Administer anticoagulants as prescribed.
The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?
Ask the client to urinate and empty her bladder.
The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first?
Assist the client to the bathroom to void and then reassess the fundus.
After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?
At the level of the umbilicus
The postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Which determination should the nurse make based on this information?
The bright red bleeding is abnormal and should be reported.
In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply.
Change breast pads frequently. avoid the use of soap on your nipples. Intermittently expose your nipples to the air.
The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma?
Changes in vital signs
The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is most important for the nurse to take at this time?
Check the uterine fundus and lochia.
A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should take which approach as the first step to support the client psychologically?
Collect data regarding how the client perceived the event.
The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client?
Complete the entire antibiotic regimen.
A client arrives to the postpartum unit following the delivery of her newborn premature infant. On data collection, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate?
Covering her with a warm blanket
The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms?
Dyspnea, tachypnea, and tachycardia
The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms? Select all that apply.
Ecchymosis Epistaxis Hematuria
The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals?
Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours
The nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage. The nurse plans care based on which information related to the condition?
Fewer muscle fibers in the lower segment of the uterus will result in poor contractions.
It has been 12 hours since a client's delivery of a newborn. The nurse assesses the mother for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? Refer to figure.
Figure A
When the client has been given instructions about postoperative complications following cesarean delivery, the nurse interprets that the client requires clarification of the information when the client identifies which situation as a reason to notify her primary health care provider?
Her temperature is 99° F.
The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?
Keep the client and her family members informed of her progress.
A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterus to determine if the placenta has detached. Which findings indicate to the nurse that placental detachment has occurred? Select all that apply.
Lengthening of the umbilical cord Sudden gush of dark blood from the vagina Appearance of fetal membranes at the introitus
A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which findings? Select all that apply.
Less pain Less blood loss More likely to extend with birth of LGA infant
A woman received a subarachnoid block before delivery. In order to prevent the associated side effect of this type of anesthesia, the nurse would include in the teaching plan that the patient should:
Lie flat on her back for several hours.
A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?
Massage the breasts before feeding to stimulate let-down.
1. The nurse reviews for the childbirth preparation class the rationales for labor induction, which are:
Maternal diabetes Placental insufficiency
The initial nursing action immediately after an epidural block is initiated for a laboring woman would be to:
Measure the womans blood pressure
The nurse is assigned to care for a client who received methylergonovine maleate in the immediate postpartum period. The nurse determines the medication is effective when the client makes which statement?
My afterpains are really strong."
A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. The nurse planning discharge instructions would teach the woman to:
Notify her obstetrician for a temperature above 37.8 C.
During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae which seems to occur with every breath she takes. The nurse should:
Notify the charge nurse immediately
The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action?
Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).
A second-day postpartum client diagnosed with a stable cardiac condition has scant lochia with a foul odor and a temperature of 102.2° F. The primary health care provider suspects infection and writes prescriptions to treat the client. Which prescription written by the primary health care provider should the nurse implement first?
Obtain culture and sensitivity of lochia and urine.
Which nursing actions should decrease the discomfort of an episiotomy? Select all that apply.
Performing sitz baths Applying ice packs to the perineum for the first 12 to 24 hours
A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client?
Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.
The nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?
Postpartum hemorrhage
The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?
Red Rationale: The color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days. The color of the lochia then changes to a pinkish-brown and occurs from day 4 to 10 postpartum. Finally, the lochia changes to a creamy white color that occurs from day 10 to 14 postpartum.
While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. The nurses initial action is:
Reposition the woman on her side.
A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response?
Request to hold the infant following delivery
A postpartum client asks the nurse when she may resume sexual activity. Which response should the nurse give to the client?
Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped.
As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client indicates that the client understands the instructions?
She should alternately contract and relax the muscles of the perineal area.
The nurse discussing nonpharmacological forms of pain relief will focus on methods of: Select all that apply.
Skin stimulation Diversion and distraction Breathing techniques
A woman 2 weeks past her expected delivery date who is receiving an oxytocin infusion to induce labor begins to have contractions every 90 seconds. The nurse's initial action should be to:
Stop the oxytocin infusion.
A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation?
The client is required to stay on bed rest.
The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding?
The finding is normal.
After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement?
The only medications that I will take are prenatal vitamins and stool softeners."
The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which?
The presence of infection Rationale: Lochia, the discharge present after birth, is red the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor similar to the odor of menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids and ambulate are not accurate interpretations related to the assessment finding.
The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?
The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day
An elective cesarean delivery is being planned for a pregnant client. The nurse is reviewing the plans for the surgery with the client. A low transverse uterine incision will be used. The client asks the nurse to explain why this approach is being used. The nurse's response is based on which premise?
This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.
The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding should indicate which accurate interpretation to the nurse?
This may be a sign of hemorrhage or shock.
The nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in the neonate? Select all that apply.
Tremors Irritability Hypertension Exaggerated startle reflex
Oxytocin is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication?
Uterine contractions
After the physician discussed general anesthesia with a woman in labor, the nurse determines the woman understood the explanation when she says food and fluids are restricted for several hours prior to delivery to prevent:
Vomiting and aspiration
A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Which activity should the nurse implement as part of the method to accurately determine the amount of flow for documentation purposes?
Weigh the perineal pad before and after use.
A woman who is 33 weeks pregnant is admitted to the obstetrical unit because her membranes ruptured spontaneously. She must be closely observed for signs of:
chorioamnionitis
The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?
he progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day
A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for the associated side effect of:
marked hypotension
When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which nursing action is appropriate?
notify the health care provider
The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?
red
The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood loss and shock?
An increase in the pulse rate from 88 to 102 beats per minute
Oxytocin is utilized in multiple ways in the labor and delivery unit. The nurse correctly identifies which purposes for administering this medication? Select all that apply.
Aids milk let down Controls uterine atony Augments labor contractions Stimulates uterine contractions
The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?
Ambulate frequently.
Following an amniotomy, the nursing assessment that should be reported immediately is:
Amniotic fluid is watery and pale green
The massage technique that stimulates the large-diameter fibers in order to block impulses from the small-diameter fibers is
Effleurage
A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago. The mother's temperature is 100° F (38° C). What is the initial nursing action?
Encourage oral fluid intake.
A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breastfeed her infant. Which should the nurse tell the client?
"Breastfeed from the left breast and gently pump the right breast."
After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement?
"The only medications that I will take are prenatal vitamins and stool softeners."
In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply.
-Change breast pads frequently. -Avoid the use of soap on your nipples. -Intermittently expose your nipples to the air.
The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms? Select all that apply.
-Epistaxis -Hematuria -Ecchymosis
The nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery?
An adolescent experiencing an emergency cesarean delivery for fetal distress
The nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate?
Instruct the mother to request help when getting out of bed.
The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing?
Postpartum hemorrhage
A new mother is attempting to breastfeed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breastfeeding the newborn?
Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.
The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which?
The presence of infection
The nurse is assisting in developing a plan of care for a client preparing to breastfeed. In planning care, which factor is most significant in teaching a client to breastfeed?
A positive nurse-client relationship
The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions are included in the plan of care? Select all that apply.
Applying warm compresses to the affected area as prescribed Maintaining bed rest Elevating the affected extremity
The nurse who encourages the gate control theory of pain control would advise a woman in labor and her partner to use which nonpharmacological method of pain management?
massage
The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, which nursing action is the most appropriate?
Have the mother place the infant in the bassinet and assist the mother in dressing the baby.
15. A pulsating structure is felt during a vaginal examination of a woman in labor. To prevent compression of a prolapsed cord, the nurse would position the woman:
On her back with her head lower than the rest of her body
The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the primary health care provider?
Pain, redness, or swelling in the breasts
The nurse reinforces home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?
If I develop a fever, I will call my doctor.
The nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the client's participation in infant care?
Encouraging the client to take pain medication as prescribed
The nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action is appropriate?
Encourage oral fluids.
