quiz 2- postpartum

Which of the following nursing outcomes related to the nursing diagnosis, "Risk for intrauterine infection related to vaginal delivery" should be included in the plan of care? (SELECT ALL THAT APPLY). a. The client changes her peri-pad at least once a day throughout hospitalization. b. The client will use her peri-bottle after every void throughout hospitalization. c. The client will drink sufficient quantities of fluid throughout hospitalization d. The client will report that lochia is not foul-smelling throughout hospitalization. e. The client will have a normal temperature within 24 hours of delivery.

...

What is the most important assessment in the immediate postpartum period for the nurse to make? a. Maternal vital signs b. Breast feeding potential c. Bladder assessment d. Fundal assessment

d. Fundal assessment

The nurse has taught a newly admitted patient to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? (SELECT ALL THAT APPLY). a. The client uses her peri-bottle each time she goes to the bathroom to void/stool. b. The client applies a fresh peri-pad after each void/stool c. The client wipes from back to front after voiding. d. The client washes her hand after the procedure. e. The woman mixes warm tap water with hydrogen peroxide in the peri-bottle.

a, b, d

The nurse is assigned to care for 4 new mothers on the postpartum floor. The nurse knows that the patient who is most likely to have the most painful after-birth pains is: a. G4P3 breastfeeding mom b. G1P0 bottle-feeding mom c. G1P0 who delivered a 5lb 6oz baby d. G1P0 who delivered 5 lb. twin boys and is bottle feeding

a. G4P3 breastfeeding mom

The client who has decided to breast feed her baby has just delivered her newborn baby girl and is in recovery. Which of the following maternal hormones will increase sharply postpartum in order for the production of milk to occur? a. Prolactin b. Estrogen c. Progesterone d. Human chorionic gonadotropin

a. Prolactin

A woman 48 hours postpartum is complaining of profuse diaphoresis at night. She has no other complaints of discomfort. Which of the following actions by the nurse is most appropriate? a. Reassure the woman this is normal. b. Take the woman's temperature. c. Advise the woman to decrease her fluid intake. d. Notify the newborn's pediatrician.

a. Reassure the woman this is normal.

The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 4 day old baby girl. The client stated that her breasts are firm, red, and very shiny. Which of the following is the best action for the nurse to advise the client to perform? a. Apply lanolin to her breasts and nipples every 3 hours. b. Intermittently apply ice packs to the axillae and breast regions or cabbage leaves c. Manually express all milk in the breasts every 3 hours. d. Ask the primary health care provider to order a pill to stop milk production.

b. Intermittently apply ice packs to the axillae and breast regions or cabbage leaves

The nurse has received an order for an early discharge for a patient that delivered a few hours ago. The assessment that is most concerning over an early discharge is: a. Patient expresses lack of confidence with infant bathing. b. Patient's fundus is boggy. c. Patient has moderate amount rubra lochia. d. Patient has perineal redness and edema

b. Patient's fundus is boggy.

The nurse receives the following report on a newly delivered client: 21 years of age; married; G1P1001; Spontaneous vaginal delivery with no episiotomy or lacerations; vitals: 99.0F, 88, 16, 120/70; fundus firm at umbilicus with moderate rubra lochia; ambulated to the bathroom to void 4 times; breastfeeding every two hours. Which of the following nursing diagnoses should the nurse include in this client's care plan? a. Fluid volume deficit r/t excess blood loss b. impaired skin integrity r/t vaginal delivery c. Knowledge deficit r/t lack of parenting experience d. Impaired urinary elimination r/t excessive output

c. Knowledge deficit r/t lack of parenting experience

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? a. Use a nipple shield at each breastfeeding b. Clean the nipples with soap three times a day c. Rotate the baby's position at each feeding d. Bottle feed for two days and then resume breastfeeding

c. Rotate the baby's position at each feeding

A breast-feeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? a. She pumps her breasts after each feeding. b. She feeds her baby on each side for 5 minutes. c. She feeds her baby every 2-3 hours. d. She supplements each feeding with formula.

c. She feeds her baby every 2-3 hours.

The new mom is tearful and wonders if this is a sign of postpartum depression? The nurse correctly answers: a. "Yes, being tearful in the hospital on postpartum day 3 is one of the signs of postpartum depression." b. No, but it is unusual for you to be so emotional so quickly." c. "I will get the doctor to order you an antidepressant." d. "No, this is normal and is known as the postpartal "baby blues".

d. "No, this is normal and is known as the postpartal "baby blues".

The nurse is assessing a woman who delivered 12 hours earlier. Which of the following findings would the nurse expect to find at this point? a. Fundus 1 cm above the umbilicus, lochia rubra b. Fundus 2 cm below the umbilicus, lochia rubra c. Fundus 2 cm above the umbilicus, lochia rubra d. Fundus at the level of the umbilicus, lochia rubra

d. Fundus at the level of the umbilicus, lochia rubra

A primipara that delivered two hours ago requests that the nurse take care of the baby in the nursery so that she can get a nap. Based on this information, the nurse concluded that the woman is exhibiting signs of which of the following? a. Poor bonding b. Letting Go Stage c. Postpartum Depression d. Taking-In Stage

d. Taking-In Stage

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? a. The woman should pump and dump her breast milk for 1 week. b. surgical masks must be worn by the mother when she holds the baby. c. Antibodies transported through the breast milk will protect the baby. d. The woman should not become pregnant for at least 4 weeks.

d. The woman should not become pregnant for at least 4 weeks.