Select all that apply questions, medications, and hard questions
A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply. A. active bowel sounds B. abdominal pain C. passing gas D. nondistended abdomen E. tender abdomen
A,C,D
Client teaching is conducted throughout a client's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? A. resumption of intercourse B. infant formula selection C. resumption of prepregnancy diet D. activity E. signs and symptoms of infection
A,D,E, R:The correct answers give information on managing changes in her new role as a mother. The assumption cannot be made that her pre pregnancy diet is still appropriate, and the formula choice should be discussed with her pediatrician.
A client who gave birth 18 hours ago is experiencing a change in lochia flow from scant to moderate. Prioritize the actions the nurse would take to assess the client's fundus. All options must be used. A. Assess blood pressure B. Assist the mother to empty her bladder in the bathroom C. Increased oxytocin or breastfeed the newborn D. Palpate the fundus E. Notify HCP F. Massage fundus if boggy
A. Assist the client to empty her bladder in the bathroom. B. Palpate the fundus. C. Massage the fundus if boggy. D. Increase IV oxytocin or breastfeed the newborn. C. Assess blood pressure. D. Notify the primary care provider.
A client who has given birth a week ago reports discomfort when defecating and ambulating. The birth involved an episiotomy. Which suggestions should the nurse provide to the client to provide local comfort? Select all that apply. A. Maintain correct posture. B. Use of warm sitz baths. C. Use of anesthetic sprays. D. Use good body mechanics. E. Use of witch hazel pads.
B,C,D R:The nurse should tell the client to use warm sitz baths, witch hazel pads, and anesthetic sprays to provide local comfort. Using good body mechanics and maintaining a correct position are important to prevent lower back pain and injury to the joints.
A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used. A. achievement of the parental role B. commmitment, attachment, and preparation for an infant C. moving toward a new normal routine D. acquaintance with and increasing attachment to the infant
1. Commitment, attachment, and preparation for an infant 2. Acquaintance with and increasing attachment to the infant 3. Moving toward a new normal routine 4. Achievement of the parental role R: Although the stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners, transitioning to parenthood (Mercer, 2006), involves four stages: commitment, attachment, and preparation for an infant during pregnancy; acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth; moving toward a new normal routine in the first 4 months after birth; and achievement of a parenthood role around 4 months.
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. A. decreased interest in life B. inability to concentrate C. manifestations of mania D. loss of confidence E. bizarre behavior
A,B,D R:The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis.
A client in her 42nd week of pregnancy is undergoing a scheduled induction of labor based on consideration of which factors? Select all that apply. A. fetal size B. cervical ripeness C. abnormal fetal presentation D. complete placenta previa E. gestational age
A,B,E R:Factors that the care provider should consider when deciding if and when to induce labor include cervical ripeness, gestational age and fetal size, fetal pulmonary maturity, fetal ability to tolerate labor, uterine sensitivity to the proposed induced method, and maternal condition. The health care provider does not confirm abnormal fetal presentation and complete placenta previa when deciding to induce labor. Abnormal fetal presentation and complete placenta previa are considered contraindications to the induction of labor and not as positive factors.
A primigravida at 28 weeks' gestation comes to the clinic for a check-up. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with preterm birth would the nurse discuss with the client? Select all that apply. A. previous cesarean birth B. history of previous preterm birth C. large-for-gestational age fetus D. current multiple gestation pregnancy E. uterine or cervical abnormalities
A,B,E R:The top three risk factors for premature birth are history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities.
A nurse is reviewing the medical record of a postpartum woman in preparation for assessment. Which factor would the nurse identify as increasing the woman's risk for infection? Select all that apply. A. denuded endometrial arteries B. white blood cell count 25,000/mm³ C. hemoglobin 11.0 g/100 mL D. urinary stasis E. episiotomy
A,D,E R: The urinary system after birth is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity, such as an episiotomy. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation. A hemoglobin finding lower than 10.5 g/100 ml suggests anemia
A nurse is caring for a client who is experiencing acute onset of dyspnea and hypotension. The health care provider suspects the client has amniotic fluid embolism. What other signs or symptoms would alert the nurse to the presence of this condition in the client? Select all that apply. A. pulmonary edema B. arrhythmia C. hyperglycemia D. hematuria E. cyanosis
A,E R:The nurse should monitor cyanosis and pulmonary edema when caring for a client with amniotic fluid embolism. Other signs and symptoms of this condition include hypotension, cyanosis, seizures, tachycardia, coagulation failure, disseminated intravascular coagulation, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest. Arrhythmia, hematuria, and hyperglycemia are not known to occur in cases of amniotic fluid embolism. Hematuria is seen in clients having uterine rupture.
Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which medication would the nurse administer as prescribed after repositioning?
An oxytoxic agent R: The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion.
A client is 2 weeks past her due date, and her health provider is considering whether to induce labor. Which conditions must be present before induction can take place? Select all that apply. A. The cervix is ripe. B. There is absence of eclampsia. C. The fetus is in a longitudinal lie. D. A presenting part is engaged. E. Maternal blood pressure is normal. F. Cephalopelvic disproportion is present.
C. The fetus is in a longitudinal lie. A. The cervix is ripe. D. A presenting part is engaged. R:Before induction of labor is begun in term and postterm pregnancies, the following conditions should be present: the fetus is in a longitudinal lie; the cervix is ripe, or ready for birth; a presenting part is engaged; there is no cephalopelvic disproportion; and the fetus is estimated to be mature by date (over 39 weeks) or demonstrated by a lecithin/sphingomyelin ratio or ultrasound biparietal diameter to rule out preterm birth. Normal maternal blood pressure and absence of eclampsia are not conditions required for induction; in fact, severe hypertension and eclampsia are conditions that may necessitate induction.
A nurse is presenting an in-service program about complications that can arise during labor. The nurse determines that the teaching was successful when the group correctly chooses which findings as suggesting an amniotic fluid embolism? Select all that apply. A. Slow onset of fetal distress B. Maternal tachycardia C. Maternal hypotension D. Sudden onset of respiratory distress E. Acute, continuous abdominal pain
D,E R:The client with an amniotic fluid embolism commonly reports difficulty breathing. Other signs include hypotension, tachycardia, cyanosis, seizures, coagulation difficulties, and uterine atony with subsequent hemorrhage. If the mother is still in labor, the fetus may demonstrate distress with bradycardia occurring in most cases. A sudden onset of fetal distress and acute continuous abdominal pain is more often associated with uterine rupture.
In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. A. women who had difficulties with breastfeeding in the past B. women on antineoplastic medications C. women with more than one infant D. women using street drugs E. women on antithyroid medications
A,B,C R:While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. A. Place baby in uninterrupted skin-to-skin contact with the mother. B. Help the mother initiate breastfeeding within 30 minutes of birth. C. Encourage breastfeeding of the newborn infant on demand. D. Provide breastfeeding newborns with pacifiers. E. Give newborns water and other foods to balance nutritional needs.
A,B,C R: The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. A. early ambulation B. hydramnios C. prolonged labor D. empty bladder E. breastfeeding F. uterine infection
B,C,F R:Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breast-feeding, early ambulation, and an empty bladder would facilitate uterine involution.
What findings should the nurse report to the doctor for a postpartum client who delivered 12 hours ago? Select all that apply. A. Lochia rubra B. Episiotomy appears edematous C. Temperature of 101.8°F (38.8°C) D. Fundal height level of one fingerbreadth above the umbilicus E. White blood cell count of 28,000
C,D R:The uterine fundus should be one fingerbreadth below, not above, the umbilicus. Maternal temperature does increase slightly after delivery but 38.8°C (101.8°F) is too high and the doctor needs to be made aware of it. All other findings are normal.
The nursing student correctly identifies which risk factors for developing dystocia? Select all that apply. A. excessive analgesia B. maternal exhaustion C. multiple gestation D. epidurals E. maternal diabetes F. high fetal station at complete cervical dilation G. shoulder dystocia
A,B,C,D,F,G R:Early identification and prompt interventions for dystocia are essential to minimize risk to the woman and fetus. Factors associated with increased risk for dystocia include epidurals, excessive analgesia, multiple gestations, maternal exhaustion, ineffetive pushing technique, longer first stage of labor, fetal birth weight, maternal age of >35, ineffective uterine contractions, and high fetal station at complete cervical dilation.
The nurse explains to a client who recently gave birth that she will undergo both retrogressive and progressive changes in the postpartal period. Which changes are retrogressive? Select all that apply. A. contraction of the cervix B. decrease of pregnancy hormones C. involution of the uterus D. return of blood volume to prepregnancy level E. beginning of a parental role F. formation of breast milk
A,B,C,D R:Retrogressive changes represent a return to prepregnancy conditions and include involution of the uterus, contraction of the cervix, decrease of pregnancy hormones, and return of the blood volume to prepregnancy level. Progressive changes involve changes to new processes or roles, such as the formation of breast milk (lactation) and the beginning of a parental role.
While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply. A. fundus boggy to the right of the umbilicus B. rounded mass over symphysis pubis C. elevated oral temperature D. moderate lochia rubra E. dullness on percussion over symphysis pubis
A,B,E R:If the bladder is distended, the nurse would most likely palpate a rounded mass at the the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4 degrees F (38 degrees C), infection is suggested.
A mother who just given birth has difficulty sleeping despite her exhaustion from labor. What are the causes of this inability to rest? Select all that apply. A. inability to get adequate pain relief B. bottle feeding C. excess fatigue and overstimulation by visitors D. frequent trips to the bathroom due to diuresis E. crying baby
A,C,D,E R: The period before labor and birth can be uncomfortable for the mother, thus preventing adequate rest and creating a sleep hunger. The early postpartum period involves many adjustments that can take a toll on the mother's sleep.
A nursing student doing a rotation in labor and birth correctly identifies which medications as most commonly used for tocolysis? Select all that apply. A. indomethacin B. nitroglycerin C. atosiban D. magnesium sulfate E. nifedipine
A,C,D,E, R:Medications commonly used for tocolysis include magnesium sulfate, atosiban, indomethacin, and nifedipine. These drugs are used "off label," meaning that they are effective but have not been officially tested and developed for this purpose by the Food and Drug Administration.
The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply. A. Inspect the episiotomy for sutures and to ensure that the edges are approximated. B. Palpate the episiotomy for pain. C. Gently palpate for any hematomas. D. Place the patient in Trendelenburg position for inspection. E. Note any hemorrhoids.
A,C,E R:The client is placed in the Sims position, not Trendelenburg position, for inspection. The nurse will then use a light to look at the perineum, noting any hemorrhoids, inspecting the episiotomy (if present) and palpating for any hematomas. The episiotomy is not palpated due to the pain associated with it, and the nurse can visually inspect it.
A nurse is to care for a client during the postpartum period. The client reports pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? Select all that apply. A. Breasts are hard. B. Breasts are soft. C. Nipples are fissured. D. Breasts are tender. E. Nipples are cracked.
A,D R: Engorged breasts are hard and tender, and the nurse should assess for these signs. Improper positioning of the infant on the breast, not engorged breasts, results in cracked, blistered, fissured, bruised, or bleeding nipples in the breastfeeding woman.
A delivery room nurse notes that after the provider attempts to remove the placenta, a ball of tissue appears in the woman's vagina accompanied by massive amount of gushing blood. Immediately the woman's vital signs reveal: BP 70/48, pulse rate 150, mucous membranes are pale. Which interventions should be the priority for the delivery room nurse? Select all that apply. A. Call environmental services to mop up the blood. B. Assist the provider in pulling harder on the placenta to get it removed quicker. C. Apply oxygen mask at 10 L/min. D. Give the provider assistance by helping re-insert the uterus back through the cervical opening. E. Discontinue the IV oxytocin infusion.
C, E R:Because uterine inversion occurs in various degrees, the inverted fundus may lie within the uterine cavity or the vagina, or in total inversion, it may protrude from the vagina. An IV fluid line should be inserted if one is not already present (use a large-gauge needle). If a line is already in place, open it to achieve optimal flow of fluid to restore fluid volume. Administer oxygen by mask, and assess vital signs. Oxytocin, if being used, should be discontinued because it makes the uterus more tense and difficult to replace. Never attempt to replace an inversion, because handling of the uterus could increase the bleeding. Never attempt to remove the placenta if it is still attached, because this would create a larger surface area for bleeding. Blood on the floor is a very low priority at this time.
A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply. A. uterine infection B. prolonged labor C. breastfeeding D. hydramnios E. early ambulation
C,E R:Factors that inhibit involution that would result in subinvolution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.