NU 201 Maternity Exam 3
A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client?
Complete the full course of antibiotic prescribed, even if you begins to feel better.
A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?
"I should brush my teeth vigorously to stimulate the gums."
A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?
"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."
A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?
1000 ml
The nurse is caring for several postpartum clients and notes various warning signs that are concerning. Which client should the nurse suspect is developing endometritis?
A woman with diabetes, vaginal birth, HR 110, temperature 101.7°F (38.7°C) on the third postpartum day. The next day, appears ill; temperature now 102.9°F (39.3°C); WBC 31,500/mm3; negative blood cultures.
The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?
Assess the woman's fundus.
The nurse notes uterine atony in the postpartum client. Which assessment is completed next?
Assessment of the perineal pad
Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication?
At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.
A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching?
Avoid over-the-counter (OTC) salicylates.
A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?
Check the lochia.
Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?
Perform handwashing before breastfeeding.
Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?
She should continue to breastfeed; mastitis will not infect the neonate.
The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?
Symptoms include fever, chills, malaise, and localized breast tenderness.
Which situation should concern the nurse treating a postpartum client within a few days of birth?
The client feels empty since she gave birth to the neonate.
A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?
administration of platelet transfusions as prescribed
A nurse is assigned to care for a client with lacerations. The nurse knows that which factor would be the most likely cause of lacerations of the genital tract?
birth of a large newborn
A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential?
meticulous handwashing
The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client?
deep vein thrombosis
Two weeks after a vaginal birth, a client presents with low-grade fever. The client also reports a loss of appetite and low energy levels. The health care provider suspects an infection of the episiotomy. What sign or symptom is most indicative of an episiotomy infection?
foul-smelling vaginal discharge
A nurse is preparing for a class to teach pregnant women and their partners about postpartum complications. Which measure would be most important for the nurse to emphasize as helping to prevent postpartum infection?
handwashing
A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?
lack of pleasure
A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.
inability to concentrate loss of confidence decreased interest in life
The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?
drop in estrogen and progesterone levels after birth
A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?
endometritis
When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?
massaging the fundus firmly
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?
500 mL
A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?
Dorsiflex her right foot and ask if she has pain in her calf.
In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?
"How much blood was on the two pads?"
The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply.
"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." Correct response: "The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider."
The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?
Assess for warmth, erythema, and pedal edema.
The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?
Blood pressure, pulse, reports of dizziness
A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction?
Finish all antibiotics to decrease a genital tract infection.
A postpartum client who was discharged home returns to the primary health care facility after 2 weeks with reports of fever and pain in the breast. The client is diagnosed with mastitis. What education should the nurse give to the client for managing and preventing mastitis?
Perform handwashing before and after breastfeeding.
Which postpartum clients would require the nurse to intervene? Select all that apply.
Primipara with vital signs including temperature 100.2°F (37.9°C), blood pressure 140/86, pulse 124, respiratory rate 12. Multipara with vital signs including temperature 99°F (37.2°C), blood pressure 136/84, pulse 96, respiratory rate 32. Postpartum client with urine output of 30 ml/hour for 2 hours. First day postpartum client with blood pressure 84/48, pulse 128, respiratory rate 16. Primipara with vital signs including temperature 100.2°F (37.9°C), respiratory rate 28, oxygen saturation 94%.
The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?
The bladder is distended.
The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?
palpate her fundus
Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of:
postpartum depression.
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?
postpartum psychosis
What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?
Oxytocin
Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?
applying ice
The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?
Call her caregiver if lochia moves from serosa to rubra.
The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?
Infection
The nurse is caring for a woman who experienced a vaginal birth 6 hours prior. The health care provider is concerned the woman may have retained placental tissue. What assessment finding would alert the nurse to further assess the client for complications of retained placental tissue?
The client's pulse is 130 beats/min at rest and base line was 98 beat/min.
The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?
Uterine atony
What postpartum client should the nurse monitor most closely for signs of a postpartum infection?
a client who had a nonelective cesarean birth
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?
uterine atony