NSG 3500 - Exam 3 Testbank

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? Calculate to the nearest tenth. ___________ mL

0.6 mL

A nurse is performing a postpartum assessment on a client on postpartum day one. The nurse notes the following four signs/symptoms. The nurse should report which of the signs/symptoms to the client's healthcare practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

1

A postoperative cesarean client who was diagnosed with severe pre-eclampsia 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.

1

A postpartum nurse is caring for a client who received epidural anesthesia during her labor and delivery. The nurse should advise the woman 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

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 fifth suck. 3. The baby's pre- and postfeed weight change is 20 milliliters. 4. The mother squeezes her nipples during manual expression.

1

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 the Trendelenburg position. 3. Notify the primary healthcare provider. 4. Increase the intravenous infusion.

1

The nurse has provided teaching to a postop cesarean client who is being discharged 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 understands that her urine may turn orange.

1

The nurse in the obstetric clinic received a telephone call from a bottle-feeding 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 healthcare provider to order a milk suppressant.

1

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 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?"

1

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

The nurse must initiate discharge teaching with the 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.

1

The obstetrician has ordered a postop 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

Which of the following complementary therapies can a nurse suggest to a multiparous 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 ice tea with lemon or lime.

1

A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella 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. Surgical masks must be worn by the mother when she holds the baby. 4. Antibodies transported through the breast milk will protect the baby.

1 1. This statement is correct. 2. 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. 3. This is unnecessary. There is no risk to the baby whether the mother is bottle feeding or breastfeeding.This statement is incorrect. There is no risk to the baby. 4. This statement is incorrect.

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. Take only ibuprofen for pain. 2. Avoid overeating dark green, leafy vegetables. 3. Drink grapefruit juice daily. 4. Report any decrease in urinary output.

2

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.

2

A client who delivered a 3,900-gram 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 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.

2

A client, G1 P0101, 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 healthcare provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

2

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 woman's periphery. 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, G1 P1, who delivered a 2,800 gram baby vaginally 30 minutes earlier, is transferred to the postpartum unit. She pushed for 45 minutes and the placenta was delivered 10 minutes later. She is receiving an intravenous with 20 units oxytocin added. The postpartum nurse questions why the oxytocin was added to the IV bag. Which of the following responses 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 assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

2

A nurse is caring for a postpartum client who has stated that she is putting her newborn son up for adoption. 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. "You want to 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

A post-cesarean section, breastfeeding client whose subjective pain level is 2/5 requests her as-needed (prn) narcotic analgesics every 3 hours. She states, "I have decided to make sure that I feel as little pain from this experience as possible." Which of the following should the nurse conclude in relation to this woman's behavior? 1. The woman needs a stronger narcotic order. 2. The woman is high risk for severe constipation. 3. The woman's breast milk volume may drop while taking the medicine. 4. The woman's newborn may become addicted to the medication.

2

A woman is receiving patient-controlled analgesia (PCA) post-cesarean section. Which of the following must be included in the patient teaching? 1. The client should monitor how often she presses the button. 2. The client should report any feelings of nausea or itching to the nurse. 3. The family should press the button whenever they feel the woman is in pain. 4. The family should inform the nurse if the client becomes sleepy.

2

During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.

2

The nurse 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. Request an order for a topical anesthetic for the mother.

2

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.

2

The nurse informs a postpartum woman that which of the following is the reason ibuprofen (Advil) is especially effective for afterbirth pains? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen can be administered in high doses.

2

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2

The nurse is caring for a client, post-op 1 day from an emergency cesarean section with her husband in attendance. 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."

2

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 such as diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills such as pumping.

2

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 advised that her Kegel exercises should be performed during all bowel movements.

2

The surgeon has removed the surgical cesarean section dressing from a postop 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 and assess for pain.

2

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 povidone-iodine after toileting.

2 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 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 checkup." 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."

3

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

3

A primipara, 2 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.

3

A woman is admitted to the postpartum unit accompanied by her wife. Which of the following statements is appropriate for the nurse to make at this time? 1. "Who were you able to ask to donate the sperm for your pregnancy?" 2. "How did you decide which of you would become pregnant?" 3. "Congratulations on being the parents of a beautiful and healthy newborn baby." 4."It must be hard to decide what to have your baby call you since you are both mothers."

3

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.

3

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. Notify the neonate's pediatrician.

3

The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong: "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.

3

A client, G1 P1, who had an epidural has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."

4

A client, G1 P1001, 1 hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

4

A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottle feed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

4

A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes.

4

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 to breastfeed exclusively.

4

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 by the nurse 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.

4

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, 82, 18; fundus firm at umbilicus; moderate lochia rubra; 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 experien

4

The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

4

client, G1 P0000, 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 the nurse to perform for this postpartum client? 1. Strongly advise the client to breastfeed her baby. 2. Reprimand the mother for causing her baby to become addicted. 3. Suggest that the nursery nurse feed the baby in the nursery. 4. Provide the client with supervised instruction on baby-care skills.

4

A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.

4 1. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client needs acetaminophen. 2. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client is infected. 3. A temperature of 100.2°F 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 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 3,000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

4 It is not recommended that breastfeeding mothers go on weight-reduction diets. In addition, it is not necessary for mothers to drink milk to make breast milk. When a breastfeeding woman has a poor diet, the quality of her breast milk changes very little. In fact, if a mother consumes a poor diet, it is her own body that will suffer. Mothers do not need to eat 3,000 calories a day while breastfeeding. 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 informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. 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. 5. Stand with her back toward the shower water.

4 and 5 are correct. It is unnecessary for a bottle-feeding mother to increase her fluid intake. It is inadvisable for a bottle-feeding mother to massage her breasts. It is inadvisable for a bottle-feeding mother to apply heat to her breasts. The mother should be advised to wear a supportive bra 24 hours a day for a week or so. The mother should be advised to stand with her back toward the warm shower water.

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 1⁄2 liter bag of D5W indicates 25,000 units of heparin have been added. How many units of heparin is the client receiving per hour? Calculate to the nearest whole. __________ units per hour.

800 units/hour

A woman is receiving Paxil (paroxetine) for postpartum depression. 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.

1

A nurse is performing a postpartum assessment on a client who delivered vaginally. 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.

1, 3, 4, and 5

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. Anasarca.

1,2

A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply. 1. Fever. 2. Flank pain. 3. Dark-colored urine. 4. Nausea. 5. Polycythemia.

1,2,3

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.

1,2,3,5

A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2

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."

2

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 (WBC) 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.

2, 3, and 4

A nurse is caring for the following four laboring patients. Which clients should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply. 1. G1 P0000, delivered a fetal demise at 29 weeks' gestation. 2. G2 P1001, prolonged first stage of labor. 3. G2 P0010, delivered by cesarean section for failure to progress. 4. G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate. 5. G4 P3003, with a succenturiate placenta.

2,5

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? Calculate to the nearest whole. ______ mL per dose.

20 mL per dose

A 2-day postpartum mother, G2 P2002, states that her 2-year-old daughter at home is very excited about taking "my baby sister" home. Which of the following is an appropriate response by the nurse? 1. "It's always nice when siblings are excited to have the babies go home." 2. "Your daughter is very advanced for her age. She must speak very well." 3. "Your daughter is likely to become very jealous of the new baby." 4. "Older sisters can be very helpful. They love to play mother."

3

Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration in 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.

3

A G2 P2002 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 rubra, 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 healthcare provider.

4

A Muslim woman requests something to eat after the delivery of her baby. Which of the following meals would be most appropriate for the nurse to give her? 1. Ham sandwich. 2. Bacon and eggs. 3. Spaghetti with sausage. 4. Chicken and dumplings.

4

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 pneumoniae. 3. Escherichia coli. 4. Candida albicans.

4

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 mL/hr." The client has 750 mL in her IV and the IV tubing delivers fluid at the rate of 10 gtt/mL. To what drip rate should the nurse set the intravenous? ______ gtt/min

42 gtt/min

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

2

A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? 1. Skim milk. 2. Ginger ale. 3. Orange juice. 4. Chamomile tea.

3

The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.

3

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.

4

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

An Asian client's temperature 10 hours after delivery is 100.2°F but, when encouraged, she refuses to drink her ice water. Which of the following nursing actions is most appropriate? 1. Replace the ice water with hot water. 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

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."

1

A client is on magnesium sulfate via IV pump for severe pre-eclampsia. 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.

1

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

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 the past 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

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

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 at high risk for thrombus formation. 2. Post-cesarean clients are at high risk for fluid volume deficit. 3. Postpartum clients are at high risk for varicose vein development. 4. Post-cesarean clients are at high risk for footdrop.

1

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 physician declares after delivering the placenta of a client during a cesarean section 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 2,000 mL. 2. Blood pressure of 160/110. 3. Jaundiced skin color. 4. Shortened prothrombin time.

1

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 nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the clients who had which of the following deliveries state that they understand why they must receive a RhoGAM injection? Select all that apply. 1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 4. Birth of Rh-negative twins at 35 weeks' gestation. 5. Delivery of a 40-week-gestation, Rh-positive baby.

1,2,3,5

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 in the near future. 4. Ask the couple whether they would like to hold the baby. 5. Advise the couple that the baby's death was probably for the best.

1,2,4

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? Select all that apply. 1. Gently massage the areas toward the nipple, especially during feedings. 2. Apply warmth to the areas during feedings. 3. Alternate bottle feedings with breast feedings. 4. Apply lanolin ointment to the areas after each and every breastfeeding. 5. Feed from the affected breast first.

1,2,5

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? Calculate to the nearest whole. __________ mL/hr.

18 mL/hr

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 104.6°F, 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.

2

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.

2

A couple accompanied by their 5-year-old daughter has 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.

2

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 to receive her RhoGAM injection. 2. Make sure that the client receives a RhoGAM injection before she is discharged from the hospital. 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.

2

A nurse is performing a postpartum assessment on a client whose 30 weeks' gestation baby is in the neonatal intensive care unit. The woman states, "The baby's doctor tells me that I should pump my breast milk for the baby, but I really don't want to breastfeed." Which of the following responses is appropriate for the nurse to give? 1. "You have the right to determine which type of feeding method you wish for your baby." 2."Preterm babies tend to be healthier when they are fed breast milk instead of formula." 3."Mothers who pump milk for their babies seem to be ready to take their babies home sooner than those who bottle feed." 4. "You will be charged less money for your baby's care if you pump because your breast milk is free."

2

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.

2

A postpartum nurse notes that a woman who took fluoxetine (Prozac) daily for depression throughout her pregnancy has an order from the primary healthcare provider for the medication to be continued postdelivery. The woman wishes to breastfeed her baby. Which of the following actions is appropriate for the nurse to make at this time? 1. Inform the neonatalogist regarding the antenatal medication so that an autism assessment will be performed on the baby. 2. Ask the client's primary healthcare provider if the woman could take a different antidepressant medication postdelivery. 3. Advise the client that it would be unsafe for her to breastfeed her child. 4. Praise the client for understanding her need to take an antidepressant.

2

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 effect 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.

2

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 quickly as possible.

2

A young woman, age 12, is postpartum from a vaginal delivery. Which of the following actions is appropriate for the nurse to make at this time? 1. Ask the young woman when her boyfriend will be visiting her in hospital. 2. Report the young woman to the local child abuse agency. 3. Strongly advise the young woman always to use birth control in the future. 4. Advise the young woman that she is much too young to be having sex.

2

The mother of a neonate, 26 hours old, has asked for her prn oxycodone pain medication every 3 hours since delivery. The baby is exhibiting the following symptoms: jitters, high-pitched cry, and very loose stools. Which of the following actions would be appropriate for the nurse to make at this time? 1. Immediately report the family to the local child abuse agency. 2. Advise the mother's and baby's healthcare providers regarding the behaviors. 3. Request the client's primary healthcare provider to change the medication order. 4. Advise the client to take the oxycodone less frequently.

2

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 have my husband feed 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 the baby is being fed 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 giving the baby formula, you should wear a surgical face mask when you are around him."

3

A client on the postpartum unit is preparing to breastfeed her Down syndrome baby. Which of the following actions by the nurse is appropriate at this time? 1. To prevent the baby from becoming obese, educate the mother to allow the baby to breastfeed for only 30 minutes at each feeding. 2. Provide the mother with the same breastfeeding advice that the nurse gives to all breastfeeding mothers. 3. Assist the mother to latch her baby to the breast and educate her regarding how to assess for effective milk transfer. 4. To prevent the baby from becoming anemic, remind the mother to administer iron supplements to the baby every day.

3

A client who is post-cesarean section for severe pre-eclampsia 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 the carotid pulse.

3

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.

3

A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery with complaints of burning on urination. 2. PP2 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. PO4 from cesarean delivery with complaints of firm and painful breasts.

3

A serum electrolyte report for a client, 1 day post-cesarean delivery for eclampsia, has just been received by the nurse. The client who is consuming nothing by mouth (NPO) is receiving 5% dextrose in 1⁄2 normal saline IV at 125 mL/hr and magnesium sulfate 2 G/hr IV via infusion pump. Which of the following values should the nurse report to the surgeon? 1. Magnesium 7 mg/dL. 2. Sodium 136 mg/dL. 3. Potassium 3 mg/dL. 4. Calcium 9 mg/dL.

3

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.

3

In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)? 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. The calf of one of the woman's legs 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.

3

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).

3

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. Failed lactogenesis. 2. Dysfunctional parenting. 3. Wound dehiscence. 4. Projectile vomiting.

3

The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, 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 pre-eclampsia.

3

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.

4

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 (diphenhydramine).

4

A nurse massages the uterus of a postpartum woman after diagnosing the woman at risk for injury related to uterine atony. Which of the following outcomes would indicate that the client's condition had improved? 1. Heavy lochia flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus firm at the umbilicus.

4

A transgender client, G1 P1001, who describes himself as male has just given birth to a female baby. Which of the following statements is appropriate for the nurse to make? 1. "Are you disappointed that your baby isn't a boy?" 2. "I assume that you won't want to breastfeed your baby." 3. "Isn't it unusual for you to be a man and yet to deliver a baby?" 4. "You can go to a number of classes to learn to care for your baby."

4

A woman has just delivered a set of twins. As soon as the babies are born the mother says, "I wanted so much to breastfeed them but know that that is no longer a possibility." Which of the following statements by the nurse is appropriate at this time? 1. "It would be hard to breastfeed them both, but you could bottle feed one and breastfeed the other." 2. "It will be much easier for you to bottle feed them both. If you have another child you can breastfeed then." 3. "What about switching off days. Bottle feed one baby and breastfeed the other one day then switch babies the next day." 4. "I can show you a number of ways to breastfeed both babies and you can make plenty of milk for both of them."

4

On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 3 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?"

4

The nurse is caring for a client, G3 P2002, 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 understandable when mothers cry at a time like this."

4

The nurse is caring for a couple who is in the labor/delivery room immediately after the delivery of a dead baby who exhibited visible birth 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.

4

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

A primipara, postpartum one day from a vaginal delivery, received magnesium sulfate in labor for severe pre-eclampsia. Which of the following healthcare referrals should the nurse recommend be made for the patient? Referral to: 1. Cardiologist. 2. Gastroenterologist. 3. Hepatologist. 4. Immunologist.

1

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.

1

A client has been transferred to the post-anesthesia care unit from 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 client is receiving a blood transfusion after the delivery of a placenta accreta 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

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 mL/hr. 4. Numbness of feet and ankles.

1

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 checkup. 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

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 checkup? 1. Glucose tolerance test. 2. Indirect Coombs test. 3. Blood urea nitrogen (BUN). 4. Complete blood count (CBC).

1

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

A nurse is performing a postpartum assessment on a client who delivered by cesarean section. Which of the following actions will the nurse perform? Select all that apply. 1. Auscultate the abdomen. 2. Palpate the fundus. 3. Assess the nipple integrity. 4. Assess the central venous pressure. 5. Auscultate the lung fields.

1, 2, 3, and 5

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? Select all that apply. 1. Pain. 2. Warmth. 3. Discharge. 4. Ecchymosis. 5. Redness.

1, 2, 5

During a postpartum assessment, it is noted that a G1 P1001 woman who delivered vaginally over an intact perineum has a cluster of hemorrhoids. Which of the following 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, 2, and 5

A breastfeeding woman, 11⁄2 months postdelivery, calls the nurse in the obstetrician's office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection reflex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk.

2

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 bottle-fed milk that the mother has stored.

2

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, you should be assessed for 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 to be checked?"

3

The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary healthcare provider? 1. White blood cells, 12,500 cells/mm . 2. Red blood cells, 4,500,000 cells/mm. 3. Hematocrit, 26%. 4. Hemoglobin, 11 g/dL

3

The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.

3

The 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 the third postpartum day. 2. Administer analgesics every four hours per doctor's orders. 3. Teach the client to contract her buttocks before sitting. 4. Irrigate the incision twice daily with antibiotic solution.

3

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 the 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.

3

The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3

The 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 woman's vagina. 2. Advise the client that for the first two days she will be bleeding too heavily for a tampon. 3. Remind the client that a tampon would hurt until the soreness from the delivery resolves. 4. State that it is unsafe to place anything into the vagina until involution is complete.

4

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

4

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.

2

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.

1

Which of the following is the priority nursing action during the immediate postpartum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

1

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 1 This statement is correct. Because the vaccine is teratogenic, the best time to administer it is when the client is not pregnant. This statement is incorrect. The immune systems of women during their pregnancies and immediately postpartum are slightly depressed. This statement is incorrect. The baby will be susceptible to rubella whether or not the woman receives the vaccine.In general, insurance companies will pay for vaccinations whenever they are needed.

A client has been receiving magnesium sulfate for severe pre-eclampsia 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 bpm. 2. Urinary output 240 mL/12 hr. 3. Blood pressure 160/120. 4. Temperature 100°F.

2

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 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.

2

A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is the highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain.

2

The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

2

The nurse takes a newborn to a primipara for a feeding. The mother holds the baby en face, strokes his cheek, and states that this is the first newborn 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 newborn care is needed. 3. Poor bonding and referral to a child abuse agency is essential. 4. Poor bonding but there is potential for positive mothering.

2

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

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/mm . 3. Red blood cell count, 5 million cells/mm . 4. Hemoglobin, 15 grams/dL.

2

Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers? 1. Breastfeeding mothers usually involute completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.

2

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 the baby's positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

3

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

3

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant? 1. Assess client's fundal height. 2. Teach client how to massage her fundus. 3. Take the client's vital signs. 4. Document quantity of lochia in the chart.

3

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.

3

A client, G2 P1102, 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 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

A medication order reads: Methergine (ergonovine) 0.2 mg PO q 6 h × 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

3

A bottle-feeding woman, 11⁄2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated two pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1."You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." 2. "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." 3. "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." 4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

4

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 that 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 bedrest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please go to the emergency department."

4

A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement." 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

4

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."

4

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.

4

A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse's best response? 1. "I know that it hurts but it is very important for you to cough." 2. "Let me check your lung fields to see if coughing is really necessary." 3. "If you take a few deep breaths in, that should be as good as coughing." 4. "If you support your incision with a pillow, coughing should hurt less."

4

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 ounces yogurt mixed with 1 medium banana. 3. 12 ounces strawberry milk shake. 4. 11⁄2 cups raw broccoli.

4

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.

2

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. Prothrombin time (PT): 12 sec (normal is 10-13 seconds). 2. International normalized ratio (INR): 2.5 (normal is 1-1.4). 3. Hematocrit 55%. 4. Hemoglobin 10 g/dL.

2

On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was assessed at 11 g/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 g/dL; Hct 37%. 2. Hgb 11 g/dL; Hct 33%. 3. Hgb 10.5 g/dL; Hct 31%. 4. Hgb 9 g/dL; Hct 27%.

3

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 terrible. 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. Post-trauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

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.

3

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.

3

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 less than 1: administer 7,500 units heparin subcu If INR is 1.1 to 2: administer 5,000 units heparin subcu If INR is 2.1 to 3: administer 2,500 units heparin subcu If INR is greater than 3: administer 0 units heparin subcu The client's INR is 2.6. How many mL of heparin will the nurse administer if the available concentration of heparin is 5,000 units per 0.2 mL? Calculate to the nearest tenth. __________ mL.

0.1 mL

Which of the following nursing interventions would be appropriate for the nurse to perform to achieve this client care goal: The client will not develop postpartum 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

A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

2

A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

2 Clients are not recommended to pump their breasts after feedings unless there is a specific reason to do so.This statement is true. The best way to prevent engorgement is to feed the baby every 2 to 3 hours. 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. Clients are not recommended to supplement with formula unless there is a specific reason to do so.

The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? Select all that apply. 1. The woman performs the procedure twice a day. 2. The woman washes her hands before and after the procedure. 3. The woman sits in warm tap water for ten minutes three times a day. 4. The woman sprays her perineum from front to back. 5. The woman mixes warm tap water with hydrogen peroxide.

2 and 4

The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother

4