NCLEX - Postpartum Period
The nurse is collecting data on a neonate. Which finding indicates that the neonate's fontanels are normal? 1. They're soft to touch. 2. They're depressed. 3. They're bulging. 4. They're large and flat.
1. They're soft to touch
The nurse is discharging a 34-year-old multipara client who, after 16 hours of labor, delivered an 8-lb, 14-oz (4,032-g) baby vaginally. The nurse notes that the mother is rubella-immune with Rh-positive blood. Which client outcome takes priority for this client? 1. The client will receive Rho(D) immune globulin (RhoGAM) I.M. before discharge. 2. The client will understand the need for planned rest periods and identify a support system. 3. The client will understand and consent to a rubella vaccine before discharge. 4. The client will verbalize the importance of reporting changes in lochia flow.
4. The client will verbalize the importance of reporting changes in lochia flow.
The nurse is teaching a postpartum client how to perform Kegel exercises. What is the purpose of these exercises? 1. To prevent urine retention 2. To relieve lower back pain 3. To strengthen the abdominal muscles 4. To strengthen the perineal muscles
4. To strengthen the perineal muscles
A client who delivered by cesarean birth 3 days ago is bottle-feeding her neonate. While the nurse collects data, the client complains that her breasts are painful, hard, and warm to the touch. How should the nurse intervene? 1) Apply an elastic bandage to bind the breasts. 2) Instruct the client to stand in a warm shower and allow water to flow over her breasts. 3) Notify the physician that the client is exhibiting early signs and symptoms of a breast infection. 4) Tell the client to use a breast pump to clear the breasts of stagnant milk.
1) Apply an elastic bandage to bind the breasts.
After a vaginal delivery, a postpartum client complains of perineal discomfort when sitting. To promote comfort, the nurse should provide which instruction? 1. "Contract your buttocks before sitting or rising." 2. "Support your body weight on the arms of a chair." 3. "Place a pillow behind your back." 4. "Sit on an inflatable ring."
1. "Contract your buttocks before sitting or rising."
On examining a client who gave birth 3 hours ago, the nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which of the following actions should the nurse take? Select all that apply: 1. Begin an I.V. infusion of lactated Ringer's solution. 2. Assess the client's vital signs. 3. Palpate the client's fundus. 4. Place the client in high Fowler's position. 5. Administer a pain medication.
2. Assess the client's vital signs. 3. Palpate the client's fundus.
A client is at risk for which postpartum complication during the fourth stage of labor? Select all that apply: 1. Arrhythmias 2. Hemorrhage 3. Infection 4. Mastitis 5. Postpartum depression
2. Hemorrhage
The nurse demonstrates bathing of a neonate to a primiparous client. Which statement by the client indicates understanding? 1. "I'm going to bathe the baby in the kitchen because it's nice and warm there." 2. "I have all kinds of pretty, scented soaps and lotions to bathe the baby with." 3. "I'll sponge-bathe the baby until he is 3 months old." 4. "I'll wash the baby's chest and back first."
1. "I'm going to bathe the baby in the kitchen because it's nice and warm there."
A client has just begun taking an oral contraceptive that contains estrogen and progestin. The nurse should explain that full contraceptive benefits won't occur until the client has taken the drug for at least: 1. 10 days. 2. 2 weeks. 3. 1 month. 4. 2 months.
1. 10 days
Which client care assignment is the most appropriate assignment for a newly graduated licensed practical nurse (LPN)? 1. A 24-year-old primigravida who delivered a 6-lb, 4-oz (2,835-g) baby vaginally 4 hours ago and is unable to void 2. A 22-year-old multigravida who delivered an 8-lb (3,629-g) baby vaginally and whose fundus is 3 fingerbreadths above the umbilicus and displaced to the right 3. A 27-year-old primigravida who delivered a 7-lb, 2-oz (3,232-g) baby by cesarean delivery 1 hour ago and has stable vital signs 4. A 36-year-old multigravida who delivered a 7-lb, 4-oz (3,289-g) baby and is having difficulty breast-feeding
1. A 24-year-old primigravida who delivered a 6-lb, 4-oz (2,835-g) baby vaginally 4 hours ago and is unable to void
One day after having a cesarean birth, a client complains of incisional pain that she rates as a 3 on a 1-to-10 scale, with 10 representing the most severe pain. The physician prescribed ibuprofen (Motrin), 400 mg by mouth every 4 to 6 hours, as needed. Which intervention should the nurse take when administering this drug? 1. Administer the drug with meals or milk. 2. Obtain the client's pulse rate before administering the drug. 3. Monitor the client's blood pressure to assess for hypotension. 4. Instruct the client about ways to prevent orthostatic hypotension.
1. Administer the drug with meals or milk.
The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? 1. Apply an ice pack to her perineum. 2. Take a sitz bath. 3. Perform perineal care after voiding or a bowel movement. 4. Drink plenty of fluids.
1. Apply an ice pack to her perineum
As a postpartum client adapts to her maternal role, she progresses through several phases. During which phase does she begin to accept the neonate as a separate individual? 1. Letting-go phase 2. Taking-hold phase 3. Dependent phase 4. Taking-in phase
1. Letting-go phase
The nurse is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? 1. Risk for deficient fluid volume related to hemorrhage 2. Risk for infection related to the type of delivery 3. Acute pain related to the type of incision 4. Urinary retention related to periurethral edema
1. Risk for deficient fluid volume related to hemorrhage
A client delivered a healthy full-term baby girl 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action? 1. Tachycardia and hypotension 2. Gush of vaginal blood when the client stands up 3. Blood stain 2" (5.1 cm) in diameter on the abdominal dressing 4. Complaints of abdominal pain
1. Tachycardia and hypotension
The nurse is teaching a client how to use a diaphragm. Which instruction should the nurse provide? 1. "Insert the diaphragm 4 hours before intercourse." 2. "Leave the diaphragm in place for at least 6 hours after intercourse." 3. "Remove the diaphragm immediately after intercourse." 4. "You may use the diaphragm without spermicidal jelly or cream."
2. "Leave the diaphragm in place for at least 6 hours after intercourse."
The nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client? 1. "The client demonstrates the ability to care for the neonate completely by time of discharge." 2. "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." 3. "The client demonstrates an understanding of her physical needs related to labor and delivery." 4. "The client demonstrates an understanding of the neonate's physical needs related to labor and delivery."
2. "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment."
The nurse brings a new mother her baby for the first time approximately 1 hour after the baby's birth. After checking the identification, the nurse hands the baby to the mother. Within a few minutes, the mother begins to undress her baby. Which of the following should the nurse do? 1. Call the pediatrician and report the behavior. 2. Anticipate and support the behavior as a normal part of bonding. 3. Encourage the mother to rewrap the baby because the room is cold. 4. Take the baby back to the nursery and recheck the baby's temperature.
2. Anticipate and support the behavior as a normal part of bonding.
A clinical pathway is guiding care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The client has no episiotomy and is bottle-feeding her baby. Which outcome should be achieved within the next 8 hours? 1. Encourage intake of high-fiber foods to achieve a soft bowel movement. 2. Client will demonstrate ability to bottle-feed the neonate. 3. Client will walk 20' in the hallway unassisted. 4. Complete initial sitz bath.
2. Client will demonstrate ability to bottle-feed the neonate
Certain drugs used during the postpartum period may affect blood pressure. Which drug would decrease a postpartum client's blood pressure? 1. Oxytocin (Syntocinon) 2. Codeine phosphate 3. Acetaminophen (Tylenol) 4. Methylergonovine (Methergine)
2. Codeine phosphate
The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first? 1. Obtain a thorough health history from the client. 2. Explore her own personal beliefs and feelings about contraception. 3. Help determine the most appropriate contraceptive method for the client. 4. Perform a complete physical assessment of the client.
2. Explore her own personal beliefs and feelings about contraception.
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation? 1. Chills 2. Scant lochia rubra 3. Thirst and fatigue 4. Temperature of 100.2° F (37.9° C)
2. Scant lochia rubra
On her 3rd postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What do these findings suggest? 1. Lochia alba 2. Lochia serosa 3. Localized infection 4. Cervical laceration
3. Localized infection
The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What is the best response by the nurse? 1. "Why don't you wait and see how things go? You may be tired of breast-feeding by then." 2. "Let your day-care provider give the baby formula in a bottle, and then breast-feed when you're home." 3. "Your baby won't need breast-feeding by then, so just switch completely to formula when you return to work." 4. "You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."
4. "You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."
The uterus returns to the pelvic cavity in which of the following time frames? 1. 7 to 9 days postpartum 2. 2 weeks postpartum 3. End of the sixth week postpartum 4. When the lochia changes to alba
1. 7 to 9 days postpartum
A postpartum client who is bottle-feeding her neonate asks the nurse when she can expect her menstrual period to return. How should the nurse respond? 1. "In 1 to 2 weeks" 2. "In 3 to 4 weeks" 3. "In 7 to 9 weeks" 4. "In 10 to 12 weeks
3. "In 7 to 9 weeks"
A breast-feeding baby will turn his head toward the mother's breast in a natural instinct to find food. What is the name of this reflex? 1. Tonic neck reflex 2. Moro's reflex 3. Grasp reflex 4. Rooting reflex
4. Rooting reflex
Which assessment finding indicates that the infant isn't latching on properly during breast-feeding. 1. The baby's mouth covers the nipple and 2 to 3 cm of the areolar radius. 2. The baby's nose, cheeks, and chin are touching the breast. 3. The baby swallows audibly. 4. The baby's lips smack.
4. The baby's lips smack.
A client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate? 1. Inserting an indwelling urinary catheter 2. Performing fundal massage 3. Administering packed red blood cells 4. Performing a pad count
2. Performing fundal massage
Which physiologic response should the nurse expect during the early postpartum period? 1. Urinary urgency and dysuria 2. Rapid diuresis 3. Hypotension 4. Increased GI motility
2. Rapid diuresis
A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to: 1. use an electric breast pump. 2. apply warm, moist compresses to the breasts. 3. breast-feed every 1½ to 3 hours. 4. wear a brassiere 24 hours per day.
3. breast-feed every 1½ to 3 hours.
A postpartum client tells the nurse she isn't having regular bowel movements. The nurse should recommend that the client do what to combat constipation? 1. Eat more cheese. 2. Maintain bed rest and avoid exercise. 3. Add high-fiber foods to her diet. 4. Limit fluid intake to 32 oz daily
3. Add high-fiber foods to her diet
Which of the following options best describes the anticipated actions in the taking-hold phase of the maternal attachment process? 1. Meeting the mother's needs first 2. Looking at the infant 3. Kissing, embracing, and caring for the infant 4. Talking about the baby
3. Kissing, embracing, and caring for the infant
On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which response by the nurse would be appropriate? 1. "It isn't unusual to have those feelings after delivery." 2. "How have you coped with other problems in your life?" 3. "To whom do you usually talk when you have problems?" 4. "Don't worry. You'll be fine."
1. "It isn't unusual to have those feelings after delivery."
The nurse is collecting data on client who is 1 day postpartum. The nurse expects which normal findings? Select all that apply: 1. Lochia rubra 2. Nonpalpable fundus 3. Elevated blood pressure 4. Heart rate of 50 to 70 beats/minute 5. Engorged breasts
1. Lochia rubra 4. Heart rate of 50 to 70 beats/minute
Which of the following options is the most important aspect of nursing care in the postpartum period? 1. Supporting the mother's ability to successfully feed and care for her infant 2. Involving the family in learning how to take care of the baby 3. Providing group discussions on baby care 4. Monitoring the normal progression of lochia
1. Supporting the mother's ability to successfully feed and care for her infant
The nurse observes several interactions between a mother and her new son. Which of the following behaviors by the mother would the nurse identify as evidence of mother-neonate attachment? Select all that apply: 1. Talks and coos to her son 2. Cuddles her son close to her 3. Doesn't make eye contact with her son 4. Requests the nurse to take the baby to the nursery for feedings 5. Encourages the father to hold the baby 6. Takes a nap when the baby is sleeping
1. Talks and coos to her son 2. Cuddles her son close to her
During the postpartum period, the nurse should assess for signs of normal involution. Which of the following would indicate that the client is progressing normally? 1. The uterus is descending at the rate of one fingerbreadth per day. 2. Blood pressure drops as a result of the birth and changed circulatory load. 3. Urine output remains about the same as in the client's prenatal period. 4. Pad usage remains at 10 to 15 per day.
1. The uterus is descending at the rate of one fingerbreadth per day.
A 24-year-old multigravida client who had an uncomplicated, spontaneous vaginal delivery 7 hours ago is uninterested in her baby and wants to sleep. The student nurse assigned to care for the client is concerned and tells the licensed practical nurse (LPN) who's also assigned to her care. Which response by the LPN is most effective in educating the student nurse? 1. "It's important to observe these types of behaviors and make necessary referrals to the social worker." 2. "Extreme fatigue from the delivery is common, and new mothers initially focus on recovery and taking in the birth experience." 3. "Make sure you don't assume the care for the baby. Encourage the mother to change diapers and take responsibility for feeding." 4. "It's sad that some women don't seem to appreciate the gift of a healthy baby."
2. "Extreme fatigue from the delivery is common, and new mothers initially focus on recovery and taking in the birth experience."
A new mother who's breast-feeding asks how quickly she can expect to lose the 40 lb she gained during pregnancy. Which response by the nurse is best? 1. "The extra calories expended during breast-feeding will allow you to lose the weight gradually and effortlessly over the next few months." 2. "It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended." 3. "Breast-feeding mothers should diet until their babies are weaned." 4. "Relax and enjoy your infant. You shouldn't be worrying about your weight."
2. "It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended."
The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rho(D)-negative and her baby is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? 1. Administration of Rho(D) immune globulin I.M. to the baby within 72 hours 2. Administration of Rho(D) immune globulin I.M. to the mother within 72 hours 3. Injection of Rho(D) immune globulin to the mother during her 6 week follow-up visit 4. Administration of Rho(D) immune globulin I.M. to the mother within 3 months
2. Administration of Rho(D) immune globulin I.M. to the mother within 72 hours
The nurse is instructing the client on breast-feeding. Which instructions should she include to help the mother prevent mastitis? Select all that apply: 1. Wash your nipples with soap and water. 2. Change the breast pads frequently. 3. Expose your nipples to air part of each day. 4. Wash your hands before handling your breast and breast-feeding. 5. Make sure that the baby grasps only the nipple. 6. Release the baby's grasp on the nipple before removing him from the breast.
2. Change the breast pads frequently. 3. Expose your nipples to air part of each day. 4. Wash your hands before handling your breast and breast-feeding. 6. Release the baby's grasp on the nipple before removing him from the breast.
During an annual checkup, a client tells the nurse that she and her husband have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end? 1. It should begin early in the third trimester and end 1 month after delivery. 2. It should begin before conception and end 3 months after delivery. 3. It should begin when the client learns she's pregnant and end after delivery. 4. It should begin at about 5 months' gestation and end at facility discharge.
2. It should begin before conception and end 3 months after delivery.
A client who is breast-feeding her infant is experiencing breast engorgement. The nurse suggests breast pumping to relieve the breast engorgement. Which instruction should the nurse provide? 1. Pump each breast for 5 to 10 minutes every 3 to 4 hours around the clock. 2. Pump each breast for at least 10 minutes every 3 to 4 hours; pump at night only if she's awake. 3. Pump each breast for no more than 10 minutes every 2 hours around the clock. 4. Pump each breast for 10 minutes every 2 hours; skip one pumping at night
2. Pump each breast for at least 10 minutes every 3 to 4 hours; pump at night only if she's awake.
The nurse is assessing the psychosocial status of a postpartum client. Which finding is most likely to promote parent-neonate attachment? 1. Parental desire to bond with the neonate 2. Sustained parent-neonate contact immediately after delivery 3. Parental understanding of the importance of parent-neonate bonding 4. Previous positive childbirth experience
2. Sustained parent-neonate contact immediately after delivery
Which of the following correctly defines puerperium? 1. The first hour after birth 2. The 6 weeks following birth 3. The days spent in the hospital 4. The duration of breast-feeding
2. The 6 weeks following birth
A postpartum client is ready for discharge. During discharge preparation, the nurse should instruct her to report which of the following to her primary health care provider? 1) Episiotomy discomfort 2) Lochia alba at 2 weeks' postpartum 3) Redness, warmth, and pain in the breasts 4) A temperature of 99.2° F (37.3° C) for 24 hours or more
3) Redness, warmth, and pain in the breasts
A client with a first-degree tear and swollen perineum is 28 hours postpartum when she requests assistance with her first sitz bath. Which intervention by the nurse is necessary at this time? 1) Recommending the use of ice packs instead of a warm sitz bath 2) Making sure the temperature of the water doesn't exceed 107° F (41.7° C) 3) Requesting that the client call for assistance to walk back to bed when she's finished with the sitz bath 4) Using a topical anesthetic spray before the sitz bath
3) Requesting that the client call for assistance to walk back to bed when she's finished with the sitz bath
When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following descriptions provides an accurate picture of retention with overflow? 1. Frequent trips to the bathroom with an average output of 200 to 300 ml per void 2. Intense urge to urinate with an average output of 250 ml 3. A varying urge to urinate with an average output of 100 ml 4. Uterus displaced to the right with increased vaginal bleeding
3. A varying urge to urinate with an average output of 100 ml
The nurse is assisting in developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis Acute pain related to perineal sutures? Select all that apply: 1. Apply an ice pack intermittently to the perineal area for 3 days. 2. Avoid the use of topical pain gels. 3. Administer sitz baths three to four times per day. 4. Encourage the client to do Kegel exercises. 5. Limit the number of times the perineal pad is changed.
3. Administer sitz baths three to four times per day. 4. Encourage the client to do Kegel exercises.
When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take? 1. Apply an ice pack to the perineum. 2. Massage the uterus every 15 minutes. 3. Notify the physician. 4. Reassure the client that such bleeding is normal.
3. Notify the physician
A client says she wants to practice natural family planning. The nurse teaches her how to use the calendar method to determine when she's fertile and advises her to avoid unprotected intercourse. When teaching her how to determine her fertile period, the nurse should instruct her to: 1. abstain from unprotected intercourse between days 14 and 16 of the menstrual cycle. 2. subtract 11 days from her shortest menstrual cycle and 18 days from her longest cycle. 3. subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle. 4. add 25 days to the first day of her last menstrual period and abstain from unprotected intercourse for the next 5 days.
3. subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle.
While talking to the nurse, the parents of a neonate in the neonatal intensive care unit (NICU) express concern that they're neglecting their 3-year-old son. The nurse suggests a sibling visit. To best promote the sibling's attachment to the neonate, the nurse should: 1. provide the sibling with detailed information about the neonate's condition when he visits the NICU. 2. explain to the sibling how family life will change when the neonate goes home. 3. suggest that the sibling bring in a drawing to display near the neonate's crib in the NICU. 4. discuss ways in which the sibling can participate in the neonate's care.
3. suggest that the sibling bring in a drawing to display near the neonate's crib in the NICU.
A breast-feeding client is diagnosed with mastitis. Which nursing intervention would be most helpful to her? 1. Instructing her to breast-feed the neonate at least every 4 hours 2. Teaching her to apply a cold compress to the affected breast after each feeding 3. Recommending that she avoid wearing a brassier whenever possible 4. Advising her to massage the affected area gently while breast-feeding
4. Advising her to massage the affected area gently while breast-feeding
The nurse is preparing to perform a physical examination on a postpartum client. Which statement best explains why the nurse must wear gloves during this examination? 1. Gloves may protect the client against infectious organisms. 2. Gloves guard the client against the nurse's cold hands. 3. Gloves may protect the nurse against infectious organisms. 4. Gloves are required for standard precautions.
4. Gloves are required for standard precautions
The nurse explains to new parents the importance of maintaining their infant's safety during hospitalization. Which action best ensures the infant's safety? 1. Identifying and confronting suspicious-looking visitors 2. Encouraging the parents to room-in with the infant 3. Keeping security cameras and alarms activated at all times 4. Instructing the mother to notify staff when she showers to avoid leaving the infant unattended
4. Instructing the mother to notify staff when she showers to avoid leaving the infant unattended
A breast-feeding baby will turn his head toward the mother's breast in a natural instinct to find food. What is the name of this reflex 1. Tonic neck reflex 2. Moro's reflex 3. Grasp reflex 4. Rooting reflex
4. Rooting reflex
The nurse is reviewing the history of a postpartum client. Which history factor strongly suggests that this client will experience afterpains? 1. The client delivered at 39 weeks' gestation. 2. The client smokes cigarettes. 3. The client has decided to bottle-feed her neonate. 4. The client is a gravida 6, para 5.
4. The client is a gravida 6, para 5.
As part of the postpartum follow-up, the nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information, which of the following assessments would the nurse make? 1. The client's behavior represents signs of postpartum depression. 2. The client is acting abnormally and her physician needs to be notified. 3. A home assessment is necessary to assure the well-being of the mother and the baby. 4. This is expected behavior for a client 3 to 7 days postpartum.
4. This is expected behavior for a client 3 to 7 days postpartum.
The nurse is teaching a client about oral contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct her to: 1. take all the missed doses as soon as she discovers the oversight. 2. take two pills for the next 2 days and use an alternative contraceptive method until the next cycle. 3. take three pills for the next 3 days and use an alternative contraceptive method until the next cycle. 4. discard the pack, use an alternative contraceptive method until her menses begins, and start a new pack on the regular schedule.
4. discard the pack, use an alternative contraceptive method until her menses begins, and start a new pack on the regular schedule.
A client is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the client's risk of: 1. endometriosis. 2. female hypogonadism. 3. premenstrual syndrome. 4. tubal or ectopic pregnancy.
4. tubal or ectopic pregnancy.
What is the most likely reason for a temperature of 99.8° F (37.7° C) during the first 24 hours postpartum? 1. Puerperal infection 2. Mastitis 3. Dehydration 4. Chorioamnionitis
3. Dehydration
The nurse is caring for a client who just delivered triplets. Which intervention by the nurse is most important? 1. Assessing fundal tone and lochia flow 2. Applying a cold pack to the perineal area 3. Administering analgesics, as ordered 4. Encouraging the client to void by offering the bedpan
1. Assessing fundal tone and lochia flow
The physician prescribes phytonadione (AquaMEPHYTON), 0.5 mg I.M., for a neonate born 30 minutes ago. The nurse has a solution containing 2 mg/ml. How many milliliters of solution should the nurse administer to achieve this dose?
0.25
The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be: 1. red and moderate. 2. continuous with red clots. 3. brown and scant. 4. thin and white.
1. red and moderate.
After receiving methylergonovine (Methergine) I.M. for postpartum hemorrhage, a client is prescribed methylergonovine 0.4 mg by mouth every 6 hours. The pharmacy sends 0.2 mg tablets. How many tablets must the nurse administer with each dose?
2
Which of the following interventions would be appropriate to include in the plan of care for a client during the fourth stage of labor? 1. Vital signs and fundal checks every hour 2. Time with the baby to initiate breast-feeding 3. Catheterization to protect the bladder from trauma 4. Ice chips for the mother
2. Time with the baby to initiate breast-feeding
The nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure? 1. Washing the hands 2. Washing the hands and wearing gloves 3. Washing the hands and wearing gloves and a barrier gown 4. Washing the hands and wearing gloves, a barrier gown, and protective eyewear
2. Washing the hands and wearing gloves
After 2 days of breast-feeding, a postpartum client reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: 1. apply warm compresses to her nipples just before feedings. 2. lubricate her nipples with expressed milk before feedings. 3. dry her nipples with a soft towel after feedings. 4. apply soap directly to her nipples and then rinse.
2. lubricate her nipples with expressed milk before feedings
During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his mouth. To resolve this problem, the nurse should suggest that the mother: 1. tilt the bottle so that the nipple fills with formula. 2. stroke the neonate's lips gently with the nipple. 3. use a nipple with the largest possible openings. 4. push only the tip of the nipple into the neonate's mouth.
2. stroke the neonate's lips gently with the nipple.
In the fourth stage of labor, a full bladder increases the risk of which postpartum complication? 1. Shock 2. Disseminated intravascular coagulation (DIC) 3. Hemorrhage 4. Infection
3. Hemorrhage
A licensed practical nurse (LPN) who typically works in the neonatal intensive care unit is being cross-trained to work with postpartum clients. The charge nurse is busy with a delivery and assigns her to stock rooms, which is typically the responsibility of a nurse's aid. As she enters a client's room, the LPN notices that a client looks pale and shaky. Which action should she take? 1. Inform the nurse-manager that the client needs to be assessed by a registered nurse. 2. Quickly finish stocking the room and tell the client to press the call button for a regular staff nurse. 3. Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data. 4. Find another LPN to help assess the client.
3. Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data.
A 41-year-old multipara client had a spontaneous vaginal delivery of an 8-lb (3,629-g) baby 3 hours ago. The nurse collects the following data: "Fundus firm, three fingerbreadths above the umbilicus and deviated to the right. Perineal pad saturated after 20 minutes." Which nursing intervention by the licensed practical nurse (LPN) is best? 1. Notifying the registered nurse of the abnormal data collection findings 2. Changing the perineal pad and rechecking in 15 minutes 3. Reminding the client to void and helping her to the bathroom 4. Continuing to monitor and observe the client according to postpartum protocol
3. Reminding the client to void and helping her to the bathroom
A client, age 22, is a gravida 1, para 0. During the first 24 hours after delivery, she doesn't show consistent interest in her neonate. How should the nurse interpret her behavior? 1. The client is experiencing postpartum depression. 2. The client is questioning her role as a mother. 3. The client is showing expected behaviors for the taking-in period. 4. The client is failing to attach to the neonate.
3. The client is showing expected behaviors for the taking-in period.
The nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client? 1. "Client will state that she may attempt another pregnancy after 3 months of follow-up care." 2. "Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge." 3. "Client will state that she won't attempt another pregnancy until her human chorionic gonadotropin (hCG) level rises." 4. "Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."
4. "Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."
A client is resting comfortably 4 hours after delivering her first child. When measuring her heart rate, the nurse expects which normal finding? 1. A thready pulse 2. An irregular pulse 3. Tachycardia 4. Bradycardia
4. Bradycardia
A client delivers a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's husband seems withdrawn and barely speaks to the staff when visiting his child in the NICU. His behavior indicates that he's in which stage of grief? 1. Denial 2. Anger 3. Bargaining 4. Depression
4. Depression
A client who is breast-feeding her baby experiences pain, redness, and swelling of her left breast 9 days postpartum. She is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? 1. Wear a loose-fitting bra to avoid constricting the milk ducts. 2. Stop breast-feeding permanently. 3. Take antibiotics until the pain is relieved. 4. Use a warm, moist compress over the painful area.
4. Use a warm, moist compress over the painful area.
A client's neonate was delivered by cesarean. Which management strategy should be implemented regarding breast-feeding after this type of delivery? 1. Delay breast-feeding until 24 hours after delivery. 2. Have the mother breast-feed frequently during the day and every 4 to 6 hours at night. 3. Use the cradle hold position to avoid incisional discomfort. 4. Use the football hold to avoid incisional discomfort.
4. Use the football hold to avoid incisional discomfort.
One day after a client gives birth, the nurse performs a postpartum assessment. At this time, the nurse expects to find: 1. lochia nigra. 2. lochia alba. 3. lochia serosa. 4. lochia rubra.
4. lochia rubra.
