Normal postpartum part2-70번부터새버전
A client has been transferred to the post-anesthesia care unit following a cesarean delivery. The client had spinal anesthesia for the surgery. Which of the following interventions 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
1
A postpartum nurse is caring for a client who received epidural anesthesia during her labor and delivery. The nurse should advise the client that she may experience which of the following side effects of the medication during the postpartum period? 1. backache 2. light-headedness 3. hypertension 4. footdrop
1
An asian client's temperature 10 hours after delivery is 100.2F (37.8) but, when encouraged to drink ice water, she refuses. Which of the following nursing action is most appropriate? 1. ask the client what she would like instead 2. notify the client's healthcare provider 3. reassess the temperature in one-half hour 4. remind the client that drinking is very important
1
the nurse must initiate discharge teaching 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 client: 1. after 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
1
which of the following complementary therapies can a nurse suggest to a multiparous client 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
1
During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/ symptoms? SATA 1. pain 2. warmth 3. discharge 4. ecchymosis 5. redness
1 2 5
A nurse is performing a postpartum assessment on a client who delivered vaginally. which of the following actions will the nurse perform? SATA 1. palpate the breasts 2. auscultate the carotid 3. check vaginal discharge 4. assess the extremities 5. inspect the perineum
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A nurse is performing a postpartum assessment on a client whose baby was delivered by cesarean section. Which of the following actions will the nurse perform? SATA 1. auscultate the abdomen 2. palpate the fundus 3. assess the nipple skin integrity 4. assess the central venous pressure 5. auscultate the lung fields
1235
A client who delivered an 8lb 6oz (3900g) baby vaginally over a right mediolateral episiotomy states, " How am i supposed to have a bowel movement? the stitches are right there!" which of the following is the best response by the nurse? 1. i will call the doctor to order a stool softener for you 2. your stitches are actually far away from your rectal area 3. if you eat high-fiber foods and drink fluids you should have no problems 4. if you use your topical anesthetic on your stitches you will feel much less pain
2
A maternity nurse knows that obstetric clients are most at high risk for cardiovascular compromise during the one hour immediately following a delivery because of which of the following? 1. weight of the uterine body is significantly reduced 2. excess blood volume from pregnancy is circulating in the client's peripheral circulation 3. cervix is fully dilated and the lochia flows freely 4. maternal blood pressure drops precipitously once the baby's head emerges
2
A mother who delivered her first baby vaginally an hour ago, is transferred to the postpartum unit. She pushed for 45 minutes and the placenta was delivered 10 minutes after the birth. The baby weighted 6lbs 2oz(2800g). The client is receiving intravenous fluids with 20 units oxytocin added to 1000ml of lactated ringer's solution. The student nurse receiving report questions why the oxytocin was added to the IV bag. Which of the following response by the transferring nurse is most likely? 1. The medication was added 10 minutes ago to prevent excess bleeding during her transfer 2. the medication was added immediately after the baby's birth to promote placental delivery 3. the medication was added after the placenta was delivered because of its rapid separation 4. the medication was added while she was pushing to speed up the baby's birth
2
A nurse is caring for a postpartum client who has stated that her plans include adoption for her newborn son. The client asks the nurse to help her breastfeed her baby. Which of the following responses by the nurse is appropriate? 1. are you sure you want to try breastfeeding? you won't be able to do it once you give your baby away 2. let's place your baby on a lap pillow and have your baby face you. Then wait for the baby to open his mouth before moving the baby toward your breast 3. if you stimulate your breasts to produce milk by having the baby breastfeed, you may become engorged when your baby leaves you 4. you should be forewarned that breastfeeding is such an intimate experience that if you start feeding your baby that way, you won't want to give him up
2
The surgeon has removed the surgical cesarean section dressing from a client the day after surgery. 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.
2
The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? 1. estrogen 2. prolactin 3. human placental lactogen 4. human chorionic gonadotropin
2
A medication order reads: Methylergonovine 0.2mg PO q 6h x 4 doses. For which of the following clients should the nurse question the dose before administering the medication? SATA 1. client with heavy flow 2. client with a blood pressure of 140/90 3. client with type1 diabetes 4. client with Raynaud's disease
2, 4
A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is highest priority? 1. the client will breastfeed her baby every 2 hours 2. the client will consume a normal diet 3. the client will have a moderate lochial flow 4. the client will ambulate to the bathroom every 2 hours
3
The nurse should warn a client who is about to receive methlergonovine of which of the following side effects? 1. headache 2. nausea 3. cramping 4. fatigue
3
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 certified nursing assistant (CNA)? 1. assess client's fundal height 2. teach client how to massage her fundus 3. take the client's vital signs 4. document quantity of lochia in the chart
3
a client who is now G2 P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right midline episiotomy. Her physician has just finished repairing the incision. The client's legs are in stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. assess her feet and ankles for pitting edema 2. advise the client to stop feeding her baby while her blood pressure is assessed 3. lower both of her legs at the same time 4. measure the length of the episiotomy and document the findings in the chart
3
The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1 P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6 F(37), pulse 82, respiratory rate 18; fundus firm at umbilicus; moderate lochia rubra, ambulated 4 times to the bathroom to void; breastfeeding every 2 hours. Which of the following conditions should the nurse anticipate in planning care for this client? 1. fluid volume deficit r/t excess blood loss 2. impaired skin integrity r/t vaginal delivery 3. impaired urinary elimination r/t excess output 4. knowledge deficit r/t lack of parenting experience
4
the nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, " 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 client's vagina 2. advise the client that for the first two days she will be bleeding too heavily for a tampon 3. remind the client that a tampon would hurt until the soreness from the delivery resolves 4. state that it is unsafe to place anything into the vagina until involution is complete
4