Postpartum - Nclex

The nurse is collecting data on a client who's 6 hours postpartum following delivery of a full-term healthy NB. The client tells the nurse that she feels faint & dizzy. Which nursing action is appropriate?

Instruct the mother to request help when getting out of bed

It has been 12 hours since a clients delivery of a NB. The nurse assesses the mother for the process of involution & documents that it's progressing normally when palpation of the clients fundus is noted at which level? Refer to figure.

1

The nurse is caring for a client who's being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client?

To complete the entire antibiotics regimen

The parents of a neonate who isn't circumcised request information on how to clean the NB's penis. Which is the correct response for the nurse to make to the parents?

"Avoid retracting the foreskin to cleanse the glans because this may cause adhesions"

A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breastfeed her infant. What should the nurse tell the client?

"Breastfeed from the left breast & gently pump the right breast"

A pregnant client tests positive for the Hep B virus (HBV) & the client asks the nurse whether she'll be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client?

"Breastfeeding is allowed once the baby has been vaccinated"

The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration?

"It will help prevent & control bleeding if it occurs"

The nurse provides home care instructions to a postpartum client following a vaginal birth with an episiotomy. Which statement by the client indicates the need for further teaching?

"I can resume sexual activity at any time"

The nurse is reinforcing instructions to a postpartum cesarean delivery client who's preparing for discharge. Which statement by the client indicates a need for further teaching?

"I can start doing abdominal exercises as soon as I get home"

The nurse reinforced instructions to a new mother about how to perform postpartum exercise. The nurse determines that the client understands the instructions when she makes which statement?

"I should alternately contract & relax muscles of the perineal area"

The nurse is reinforcing instructions to a mother who's bottle-feeding a baby & who's complaining of breast engorgement. Which statement by the client indicates a need for further teaching?

"I should avoid wearing a bra at this time"

The nurse is assigned to care for a client in the immediate postpartum period who received mthylergonovine maleate. The nurse determines the medication is effective when the client makes which statement?

"My afterpains are really strong"

A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, holding & touching the baby. Which statement by the nurse should further assist the family in their initial period of grief?

"Would you like to hold your baby?"

The nurse is reviewing the procedure for vitamin K injection in a NB. Which info is included in the procedure?

Injection into the skin that has been cleansed & allowed to have alcohol dry on the puncture site for 1 min

The nurse in the postpartum unit is instructing a mother regarding lochia & the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed which amount?

8 pads a day

The nurse is reinforcing instructions to a new breastfeeding mother. Which factor is important to promote an effective & positive learning experience?

A positive nurse-client relationship

The nurse is assisting in developing a plan of care for a client preparing ro breastfeed. In planning care, which factor is significant in teaching a client to breastfeed?

A positive nurse-patient relationship

The nurse has a prescription to give a dose of Rho(D) immune globulin (RhoGam) to a client who has delivered an infant. The nurse understands that this medication will prevent the next infant from experiencing which complication?

Abdominal tenderness & chills

The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus & displaced to the right. The nurse recognizes that this finding indicates which?

Bladder distention

The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus & displaced to the right. Which intervention should the nurse do first?

Assist the client to the bathroom to void & then reassess the fundus

A delivery room nurse collects data on a mother who just delivered a healthy NB. The nurse checks the uterine fundus expecting to note which uterine fundus position?

At the level of the umbilicus

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?

At the level of the umbilicus

A new mother attempting to breastfeed for the 1st time has developed mastitis. She states "My breasts look terrible & I think that I will stop breastfeeding". The nurse plans care knowing that the clients concerned about which problem?

Body image

Then nurse suspects that the client has a pulmonary embolism when the client exhibits which s/s?

Dyspnea, Tachypnea, & tachycardia

The nurse is adding to a plan of care for a postpartum client. Which intervention would promote parent-infant bonding?

Encourage her to hold the infant even when the infant is crying

The nurse is caring for a client with placenta previa who's at a high risk for infection & hemorrhage. The nurse plans care based on which information related to the condition?

Fewer muscle fibers in the lower segment of the uterus will result in poor contractions

The nurse enters a new mother's room & finds that the mother's crying & that the infant is undressed on the bed in front of the mother. The mother looks at the nurse & says "I can't even dress this baby!" After reassuring the client which nursing action would be the most appropriate?

Have the mother place the infant in the bassinet & assist the mother in the dressing of the baby

The nurse caring for a postpartum client who's being treated for thrombophlebitis. The client's receiving an anticoagulant by IV. The nurse monitors for adverse effects of the anticoagulant by checking the client for which s/s?

Hematuria, ecchymosis, & epistaxis

The nurse is assisting in administering beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse understands that the medication should be administered by which route?

Intratracheal

When performing a postpartum assessment on a client, the LPN notes clots in the lochia. The LPN examines the clots & notes that they're larger than 1 cm. Which nursing action is appropriate?

Notify the RN

The nurse is caring for the postpartum client who's diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?

Postpartum hemorrhage

A postpartum nurse reinforces information provided to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client makes which statement?

Promotes healing of the perineum

A new mother is attempting to breastfeed to the 1st time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breastfeeding the NB?

Provide breast shells & assist the mother with using a breast pump before each feeding to make the nipples easier for the NB to grasp

The nurse palpates the fundus & checks the character of the lochia of a postpartum client with who's in the 4th stage of labor. Which lochia characteristics should the nurse expect to note?

Red

A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence?

Retained placental fragments & infections

A postpartum client asks the nurse when she may resume sexual activity. Which response should the nurse give to the client?

Sexual activity may be resumed in about 3 weeks when the episiotomy has healed & the lochia has stopped

After a precipitate delivery, the nurse notes that a new mother is passive & only touches her NB briefly with her fingertips. The nurse should do which action 1st to help the woman process what has happened?

Support the mother no matter what her reaction is to the NB

A 45 yo woman delivered her 1st baby via C-section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently & requests to have her NB infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation?

The client's required to stay on bed rest

Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression?

The mother constantly complains of tiredness & fatigue

The nurse is checking the lochia discharge on a 1 day postpartum woman. The nurse notes that the lochia is red & has a foul odor. The nurse determines that this finding indicates which?

The presence of infection

Oxytocin (Pitocin) is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication?

Uterine contractions

The nurse is collecting on a 2 day postpartum mother. The mother complains of severe pain & an intense feeling of swelling & pressure in the vulvar area. After hearing these complaints the nurse should check which as a priority?

Vulva for hematoma

The nurse has reinforced instructions to a postpartum client who's Hep B positive on how to safely bottle-feed her NB to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?

Washes & dries her hands before feeding

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement?

"I don't need birth control because I will be breastfeeding"

A new mother is seen in the health care clinic 2 weeks after the birth of a healthy NB. The mother says that she feels as though she has the flu & complains of fatigue & aching muscles. On further data collection the nurse notes a localized area of redness on the left breast & the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate?

"The infection can occur at any time during breastfeeding"

After surgical evacuation & repair of vaginal hematoma, a 3 day postpartum mother is discharged. The nurse determines that the mother needs further discharge instructions if the new mother makes which statement?

"The only medications that I will take are prenatal vitamins & stool softeners"

A postpartum client who delivered at 32 weeks would like to breastfeed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?

"You can begin pumping as soon as possible after delivery with an electric breast pump"

The nurse in the NB nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which s/s would the nurse expect to note in the neonate? Select all that apply.

- Tremors - Irritability - HTN - Exaggerated startle reflex

The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which should the nurse anticipate to the prescribed by the HCP?

Administration of subcutaneous rubella virus vaccine

The nurse is assigned to care for the client after a C-section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?

Ambulate frequently

The nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery?

An adolescent experiencing an emergency cesarean delivery for fetal distress

A client who is breastfeeding her NB is experiencing nipple soreness. To relive the soreness, which action should the nurse suggest to the client?

Begin feeding on the less sore nipple

The nurse assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery. The nurse monitors the client for complications. Which would most likely indicate a hematoma?

Changes in VS

The nurse is caring for a client during the immediate recovery phase or 4th stage of labor. Which action is important for the nurse to take at this time?

Check the uterine fundus & lochia

The nurse is collecting data on a postpartum client & performs which best interventions when checking for thrombophlebitis in the legs?

Checks the calk areas for redness or swelling

A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client's physiologically stable, the nurse should take which approach as the 1st step to support the client psychologically?

Collect data regarding hwo the client perceived the event

A client arrives to the postpartum unit following the delivery of her NB premature infant. On data collection, the nurse notes that the client's shaking uncontrollably. Which nursing action is appropriate?

Covering her with a warm blanket

The postpartum nurse is collecting data from a client who delivered a viable NB 2 hours ago. The nurse palpates the fundus & notes the character of the lochia. Which characteristics of the lochia should the nurse expect to note at this time?

Dark red lochia

The nurse is assigned care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temp & notes that it's 100.4*F. Which nursing action is appropriate?

Encourage oral fluids

A client has a cesarean delivery with a low transverse uterine incision. What is the benefit of this type of incision?

It allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregancy

Which nursing actions would decrease the discomfort of an episiotomy? Select all that apply.

-Performing a sitz bath -Applying ice packs to the perineum for the 1st 12-24 hours

The nurse is caring for a client for delivered a healthy NB via vaginal delivery. An episiotomy was performed, & the woman has developed a wound infection at the site. The nurse provides instructions to the client regarding care related to the infection. Which statement by the client indicates a need for further teaching?

"I need to isolate my infant for 48 hours after starting the antibiotics"

The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching?

"I will change the perineum pads 3 times a day"

The nurse provides instructions to a breastfeeding mother who's experiencing breast engorgement about measures that'll provide comfort. Which statement by the mother indicates an understanding of these measures?

"I'll massage the breasts before feeding to stimulate let-down"

The nurse reinforces home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?

"If I develop a fever, I will call my doctor"

The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother would indicate a need for further teaching?

"My left breast is sore, so I will only offer my right breast frequently for breastfeeding"

A postpartum client suspected of having an infection is informed that she'll be unable to have the NB present in the room with her. The nurse plans care knowing that which problem is the highest priority at this time?

Risk of ineffective bonding between the mother NB

As part of a discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client would indicate that the client understands the instructions?

She should alternately contract & relax the muscles of the perineal area

The nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse should document which expected changes?

Slowed pulse rate & elevated BP

After episiotomy & the delivery of a NB, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus & notes that it's firm. Which determination should the nurse make?

The bright red bleeding is abnormal & should be reported

The postpartum nurse is caring for a mother following delivery of a NB. The nurse performs a perineal assessment on the mother & notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus & notes that it's firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Which determination should the nurse make based on this information?

The bright red bleeding is abnormal & should be reported

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

The nurse attempts to encourage a new mother to understand & to accept the C-section that was necessary to deliver her baby rather than to focus on the surgical aspect of the procedure. Which nursing statement would provide the best encouragement?

"Tell me about the delivery of your baby"

A postpartum client with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse should make which response to the client?

"You will be at risk for developing gestational diabetes with your next pregnancy & developing diabetes mellitus"

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply

- Rest during the acute phase - Wear a supportive, non-underwire bra - Maintain a fluid intake of at least 3000mL - Continue to breastfeed if the breasts aren't too sore

Which safety measures that should be implemented when working in the NB nursery? Select all that apply.

-Adhere to standard precautions -The parents should be instructed to not release their infant to anyone wearing improper id -The mother should be finer printed & the infant should be foot printed on the id card before removing the infant from the delivery room

The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions would be included in the plan of care? Select all that apply.

-Maintaining bed rest -Elevating the affected extremity -Apply warm compresses to the affected area as prescribed

When the client has been given instructions about postop complications following cesarean delivery, the nurse interprets that the client requires clarification of the information when the client identifies which situation as a reason to notify her HCP?

Her temp is 99*F

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client the nurse should plan which action?

Keeping the client & her family members informed of her progress

In formulating the plan of care which problem is most important to address for a postpartum client who has expressed concerns about not knowing how to care for her NB?

Lack of knowledge regarding ability to care for the NB

A mother is breastfeeding her NB baby & experience breast engorgement. The nurse should encourage the mother to do which to provide relief of engorgement?

Massage the breasts before feeding to stimulate let-down

The nurse caring for a breastfeeding postpartum client plans to include avoidance of soaps on the nipples, frequent changing of breast pads, & intermittent exposure of nipples to the air. These interventions are implemented to prevent which complication?

Mastitis

The nurse is caring for a postpartum client. At 4 hours the clients temp is 102*F. Which is the appropriate nursing action?

Notify the RN, who will then contact the HCP

The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy NB infant. The occurrence of which event should be reported to the HCP?

Pain, redness, or swelling in the breasts

The nurse is caring for a client who had a C-section to deliver a nonviable fetus as a result of abruption placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what's happening & the nurse explains the condition. The spouse becomes upset & says to the nurse "I lost my baby & now my wife! What am I going to do?" Which appropriately describes the situation?

The spouse lacks hope because of the loss of baby & illness of his wife

The nurse is assisting in developing a plan of care for a client in the 4th stage of labor who received an epidural. Which problem is most likely to occur during this stage?

Urinary retention caused by the loss of sensation to void & rapid bladder filling

The nurse is monitoring a new mother for signs of postpartum depression. Which observations in the mother indicate the need for further data collection related to this form of depression? Select all that apply.

-Shows lack of interest in eating -Lacks the ability to concentrate on tasks -Complains of feeling tired all the time

The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy NB. The nurse plans to take the woman's VS at which time intervals?

Q15min for the 1st hour & then q30min for the next 2 hours

The nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which s/s should the nurse expect to note when collecting data on the client?

Regression or pregnancy sx & absence of fetal heart tones

A client's admitted to the labor & delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response?

Request to hold the infant following delivery

The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action?

Administer anticoagulants as prescribed

The nurse is checking lochia discharge on a client in the immediate postpartum period & notes that the lochia is bright red & contains some small clots. Which interpretation should the nurse make about this finding?

It's normal

A mother is breastfeeding her NB. The mother complains to the nurse that she's experiencing severe nipple soreness. The nurse should provide which suggestion to the client?

Position the NB with the ear, shoulder, & hip straight in alignment & with the baby's stomach against the mother's

The client received an epidural anesthesia during labor & delivery & had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the clients systolic BP dropped 20 points, the diastolic BP dropped 10 points, & her pulse is 120 bpm. The client's very anxious & restless. The nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis the nurse should plan which action?

Prep the client for surgery

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action?

Prepare an ice pack for application to the area

A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed & touches the infant only briefly & occasionally. How should the nurse be most therapeutic in this situation?

Provide support to the mother

The nurse in the postpartum unit is assigned to care for a client who delivered a full-term healthy baby. The nurse receives the report & is told that the mother had lost 500 mL of blood during the delivery. When checking the VS, the nurse notes that the woman's pulse if 90 bpm & is weak & thread. This finding should indicate which accurate interpretation to the nurse?

This may be sx of hemorrhage or shock

A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Whish activity is a part of the method to accurately determine the amount of flow for documentation purposes?

Weighing the perineal pad before & after use

The nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the clients participation in infant care?

Encouraging the client to take pain medication as prescribed