Nclex practice review- Postpartum – Flashcards
Unlock all answers in this set
Unlock answersquestion
A new mother attempting breast-feeding for the first time has developed mastitis. She states, "My breasts look terrible and I think that I will stop breast-feeding." The nurse plans care, knowing that the client's statement relates to:
answer
Body image
question
Choose the safety measures that should be implemented when working in the newborn nursery. Select all that apply.
answer
-Adhere to standard precautions. -The parents should be instructed to not release their infant to anyone wearing improper identification. -The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room.
question
As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she states that:
answer
She should alternately contract and relax the muscles of the perineal area.
question
A nurse is performing an assessment on a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints, the nurse specifically checks the client's:
answer
Vulva for a hematoma
question
Which of the following if noted in the new mother indicates the need for further data collection by the nurse for signs of postpartum depression?
answer
The mother constantly complains of tiredness and fatigue.
question
A nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery may support this diagnosis?
answer
Abdominal tenderness and chills
question
A client had a cesarean delivery with a low transverse uterine incision. The nurse explains the benefits of this type of incision to the client, knowing that this type of incision:
answer
Allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy
question
A nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. What intervention would best facilitate the client's participation in infant care?
answer
Encouraging the client to take pain medication as prescribed
question
A nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse instructs the mother that her calorie intake needs to increase by approximately:
answer
500 calories per day
question
A client arrives to the postpartum unit following the delivery of her newborn premature infant. On data collection, the nurse notes that the client is shaking uncontrollably. Which of the following nursing actions is appropriate?
answer
Covering her with a warm blanket
question
Oxytocin (Pitocin) is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for an effective response from the medication by monitoring for:
answer
Uterine contractions
question
It has been 12 hours since a client's delivery of a newborn. The nurse assesses the mother for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? **Refer to figure**
answer
1
question
A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago. The mother's temperature is 100° F (38° C). The initial nursing action would be to:
answer
Encourage oral fluid intake.
question
A nurse is assisting in developing a plan of care for a client preparing to breast-feed. In planning care, which factor is significant in teaching a client to breast-feed?
answer
A positive nurse-client relationship
question
A nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for more information?
answer
I can start doing abdominal exercises as soon as I get home."
question
The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. The nurse responds to the client, knowing that involution is:
answer
The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day
question
A nurse attempts to encourage a new mother to understand and to accept the cesarean 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?
answer
"Tell me about the delivery of your baby."
question
A client is admitted to the labor and delivery suite with an intrauterine fetal demise. A nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents:
answer
Request to hold the infant following delivery
question
A nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information would the nurse provide to the student?
answer
Inject into skin that has been cleansed with alcohol.
question
A postpartum client asks a nurse when she can resume sexual activity. The appropriate nursing response is which of the following?
answer
"Sexual activity can be resumed in about 3 weeks once the episiotomy has healed and the lochia has stopped."
question
A nurse is providing instructions to a client who had an episiotomy during the birthing process. Which statement by the client would indicate a need for further instructions?
answer
"I should take sitz baths three or four times a day and test the water temperature to be sure that it is at 115° F."
question
A nurse is caring for a client during the immediate recovery phase or fourth stage of labor. The nurse's important action at this time is to:
answer
Check the uterine fundus and lochia.
question
A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. The initial nursing action would be which of the following?
answer
Prepare to administer oxygen at 8 to 10 L by tight face mask.
question
A nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that the initial nursing action when performing this assessment is which of the following?
answer
Ask the client to urinate and empty her bladder.
question
A nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which of the following appropriately describes the situation?
answer
Hopelessness related to loss of the baby and illness of the spouse
question
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 makes which response to the client?
answer
"You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus."
question
A nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage, as a result of this condition. The nurse plans care based on what information related to the condition?
answer
Fewer muscle fibers in the lower segment of the uterus will result in poor contractions.
question
A nurse is reviewing the procedure for vitamin K injection in a newborn. Which information is included in the procedure?
answer
Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute.
question
A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse tells the client:
answer
To breast-feed from the left breast and gently pump the right breast
question
After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further discharge instructions if the new mother states:
answer
"The only medications that I will take are prenatal vitamins and stool softeners."
question
A nurse is checking lochia discharge in a woman in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. The nurse determines that this finding:
answer
Is normal
question
A nurse is monitoring a new mother for signs of postpartum depression. Which of the following, if noted in the new mother, would indicate the need for further data collection related to this form of depression?
answer
The mother constantly complains of tiredness and fatigue.
question
A nurse is planning for a nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?
answer
Heelstick blood glucose
question
A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. The appropriate nursing response is which of the following?
answer
"The infection can occur at anytime during breast-feeding."
question
A nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, the nurse determines that the appropriate nursing action would be to:
answer
Have the mother place the infant in the bassinet and assist the mother in dressing the baby.
question
A nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. The appropriate initial intervention in meeting the emotional needs of the client and her spouse is which of the following?
answer
Gather data from the client and spouse about the perception of the event.
question
A nurse is conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is:
answer
Prolactin
question
A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience:
answer
Less pain
question
After episiotomy and the delivery of a newborn, 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 and notes that it is firm. The nurse determines that:
answer
The bright red bleeding is abnormal and should be reported.
question
On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further instructions?
answer
"Foods and fluids that will increase urine alkalinity should be consumed."
question
A nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action would be appropriate?
answer
Encourage oral fluids.
question
A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?
answer
Macrosomia
question
A nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs?
answer
Checks the calf areas for redness or swelling
question
A postpartum client asks the nurse when she may resume sexual activity. The nurse tells the client that sexual activity may:
answer
Be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped
question
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 states that it will:
answer
Promote healing of the perineum.
question
A nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding would indicate which of the following to the nurse?
answer
This may be a sign of hemorrhage or shock.
question
A new mother is attempting to breast-feed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breast-feeding the newborn?
answer
Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.
question
A nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further instructions?
answer
"I need to isolate my infant for 48 hours after starting the antibiotics."
question
Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The nurse assigned to care for the woman ensures that which medication is readily available if respiratory depression occurs?
answer
Naloxone (Narcan)
question
A nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding may indicate:
answer
Bladder distention
question
The new breast-feeding mother has been seen in the clinic for the treatment of mastitis. The nurse knows that the mother needs further teaching when the mother states:
answer
"My left breast is sore, so I will offer only my right breast frequently for breast-feeding."
question
A delivery room nurse performs an assessment on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note that it is positioned:
answer
At the level of the umbilicus
question
A nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which of the following would most likely indicate a hematoma?
answer
Changes in vital signs
question
A nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she states that:
answer
She should alternately contract and relax the muscles of the perineal area.
question
A postpartum client who delivered at 32 weeks of gestation would like to breast-feed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?
answer
"You can begin pumping as soon as possible after delivery with an electric breast pump."
question
A nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented finding is unassociated with this disorder?
answer
The passage of bloody mucus stool
question
A nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which of the following would the nurse expect to note when collecting data on the client?
answer
Regression of pregnancy symptoms and absence of fetal heart tones
question
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 newborn?
answer
Lack of knowledge regarding ability to care for the newborn
question
A nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action would be appropriate?
answer
Instruct the mother to request help when getting out of bed.
question
The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. The nurse expects the lochia to be:
answer
Red
question
A nurse is preparing to teach a new mother to breast-feed. Which factor is important to promote an effective and positive learning experience?
answer
A positive nurse-client relationship
question
A postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Based on this information, the nurse determines that:
answer
The bright red bleeding is abnormal and should be reported.
question
The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis, the nurse would plan to:
answer
Prepare the client for surgery.
question
Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the priority nursing action is to check the:
answer
Blood pressure
question
Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following?
answer
Being affected by Rh incompatibility
question
A nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?
answer
Postpartum hemorrhage
question
While a client is holding and talking to her newborn immediately following delivery, she begins to cry. The nurse interprets this behavior as indicating the client is:
answer
Experiencing a normal response to birth
question
A nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed:
answer
Eight pads a day
question
The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse encourages the woman to take which priority action?
answer
Ambulate frequently.
question
A nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for:
answer
Hematuria, ecchymosis, and epistaxis
question
A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How will the nurse be most therapeutic in this situation?
answer
Provide support to the mother regardless of her reaction to the newborn.
question
A nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse would document which expected changes?
answer
Slowed pulse rate and elevated blood pressure
question
A nurse suspects her client has a pulmonary embolism when the client exhibits which of these signs and symptoms?
answer
Dyspnea, tachypnea, and tachycardia
question
The pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. The nurse makes which statement that will best address the client's concern?
answer
"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."
question
A nurse provides explanation to a client prescribed methylergonovine maleate (Methergine) in the immediate postpartum period regarding this medication. Which of the following statements made by the client demonstrates understanding of rationale for administration?
answer
"It will help to prevent and control bleeding if it occurs."
question
A nurse provides instructions to a breast-feeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures?
answer
"I will massage the breasts before feeding to stimulate let-down."
question
A nurse is caring for a newborn with respiratory distress syndrome (RDS). Which of the following data obtained by the nurse indicate potential complications associated with this disorder?
answer
No audible breath sounds in left lung; heart sounds louder in right side of chest
question
A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse takes which approach as the best first step to support the client psychologically?
answer
Collect data regarding how the client perceived the event.
question
A nurse is caring for a woman who has delivered a baby after a pregnancy with a placenta previa. The nurse monitors the client frequently, knowing that the client is at risk for:
answer
Postpartum hemorrhage
question
A nurse is providing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further instructions?
answer
"I should avoid wearing a bra at this time."
question
A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client:
answer
Begin feeding on the less sore nipple.
question
Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which of the following conditions is documented in the client's medical history?
answer
Peripheral vascular disease
question
After a precipitate delivery, a nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse would do which of the following first to help the woman process what has happened?
answer
Support the mother no matter what her reaction to the newborn is.
question
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 would:
answer
Keep the client and her family members informed of her progress.
question
A nurse is adding to a plan of care for a postpartum client. Which intervention will promote parent-infant bonding?
answer
Encourage her to hold the infant even when the infant is crying.
question
A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands the treatment that is necessary in this situation and prepares the client for:
answer
Emergency surgery
question
A nurse has instructed a postpartum client who is hepatitis B positive how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?
answer
Washes and dries her hands before feeding
question
A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which of the following signs, if noted in the mother, would indicate an early sign of excessive blood loss and shock?
answer
A increase in the pulse rate from 88 to 102 beats per minute
question
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:
answer
Prepare an ice pack for application to the area.
question
When the client has been given instructions about postoperative 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 health care provider?
answer
Her temperature is 99° F.
question
Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.
answer
-Adhere to standard precautions during delivery and in the nursery. -Instruct the parents to not release their newborn infant to anyone wearing improper identification. -Fingerprint the mother and footprint the infant on the identification card prior to removing the infant from the delivery room.
question
Oxytocin (Pitocin) is prescribed to be administered intravenously to a client after a cesarean delivery. The nurse understands that the action of the medication is to:
answer
Stimulate the uterus to contract, thus reducing possible blood loss.
question
A 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 of the following interventions should be included in the plan of care? Select all that apply.
answer
-Maintaining bed rest -Elevating the affected extremity -Applying warm compresses to the affected area as prescribed
question
The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). The appropriate nursing action would be to:
answer
Notify the registered nurse, who will then contact the health care provider (HCP).
question
A nurse is assisting in caring for a newborn whose mother is Rh negative. In planning the newborn's care, it would be important for the nurse to:
answer
Ask about the newborn's blood type and direct Coombs'.
question
A nurse provides home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?
answer
"If I develop a fever, I will call my doctor."
question
A nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs:
answer
Every 15 minutes for the first 2 hours
question
A nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. What action should the nurse take first?
answer
Check the blood glucose level.
question
A nurse is assigned to care for a client in the immediate postpartum period who received methylergonovine maleate (Methergine). The nurse determines the medication is effective when the client says:
answer
"My afterpains are really strong."
question
Breast-feeding instructions for the postpartum mother should include avoidance of soaps on the nipples, frequent changing of breast pads, intermittent exposure of nipples to air, and handwashing before handling the breast and before breast-feeding. The nurse understands that these measures are specific to the prevention of:
answer
Mastitis
