front 1 Which patient would be most likely to have severe afterbirth pains and request a narcotic analgesic? | back 1 Gravida 5, para 5 |
front 2 Which maternal event is abnormal in the early postpartal period | back 2 Lochial color changes from rubra to alba |
front 3 Which fundal assessment finding at 12 hours after birth requires further assessment? | back 3 The fundus is palpable two fingerbreadths above the umbilicus. |
front 4 If the patient’s white blood cell (WBC) count is 25,000/mm3 on her second postpartum day,which action should the nurse take? | back 4 Document the finding. |
front 5 Postpartal overdistention of the bladder and urinary retention can lead to which complication? | back 5 Postpartum hemorrhage and urinary tract infection |
front 6 A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best response? | back 6 They will fade to silvery lines but won’t disappear completely.” |
front 7 A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will fade after birth due to | back 7 decreased melanocyte-stimulating hormone. |
front 8 Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level? | back 8 Distended bladder |
front 9 Which situation would require the administration of Rho(D) immune globulin? | back 9 Mother Rh-negative, baby Rh-positive |
front 10 If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided? | back 10 Explanation of the risks of becoming pregnant within 28 days following injection |
front 11 Which measure is optimal in order to prevent following a cesarean birth? | back 11 Early and frequent ambulation |
front 12 To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize? | back 12 Gently palpate, applying the same technique used for vaginal deliveries. |
front 13 The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount | back 13 10 to 15 cm (4- to 6-inch) stain on the peripad |
front 14 The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary? | back 14 “If I breastfeed and supplement with formula, I won’t need any birth control.” |
front 15 The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? | back 15 Firm fundus, but excessive lochia |
front 16 To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care? | back 16 Teach the patient to perform pelvic floor exercises to combat potential stress incontinence. |
front 17 When assessing the A of the acronym REEDA, the nurse should evaluate the | back 17 edges of the episiotomy. |
front 18 Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? | back 18 Uterine fundus 2 cm above the umbilicus |
front 19 The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nursepalpates the fundus of the uterus as firm and at the umbilicus. What is the nurse’s priority action related to this finding? | back 19 Document the finding in the patient’s chart. |
front 20 The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment,the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding? | back 20 Contact the health care provider. |
front 21 The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? | back 21 No swelling or edema to the perineal area |
front 22 Which description best explains the term reciprocal attachment behavior? | back 22 Positive feedback that the infant exhibits toward parents during the attachment process |
front 23 The postpartum patient who continually repeats the story of her labor, birth, and recovery experiences is performing which of the following tasks | back 23 Making the birth experience “real” |
front 24 During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant | back 24 Formal |
front 25 The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time? | back 25 Hand the baby to the woman. |
front 26 The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The 4-year-old big brother is punching his mother on the back what should the nurse do next | back 26 No action; this is a normal family adjusting to family change |
front 27 During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby | back 27 Letting-go |
front 28 A new father calls the nurse’s station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, “She was never like this before the baby was born.”How should the nurse best respond? | back 28 Reassure him that this behavior is normal. |
front 29 To promote bonding and attachment immediately after birth, which action should the nurse take? | back 29 Assist the mother in assuming an en face position with her newborn. |
front 30 Which patient is more likely to have less stress adjusting to her role as a mother? | back 30 A 26-year-old woman who is returning to work in 10 weeks |
front 31 Which anticipatory guidance action by the nurse makes role transition to parenthood easier? | back 31 Helps the new parents identify resources. |
front 32 Which action should the nurse take in order to provide support and encouragement to the new postpartum patient? | back 32 Praise the mother’s early attempts at infant care. |
front 33 Which should the nurse do to provide support to a patient who must return to full-time employment 6 weeks after a vaginal birth? | back 33 Allow her to express her positive and negative freely |
front 34 The postpartum nurse is reviewing dietary practices for an Asian patient. Which of the following should the nurse expect to observe as a dietary practice for this culture? | back 34 Special foods brought from home. |
front 35 An example of binding in during the postpartum period is a | back 35 new mother telling her friends all about her labor and birth experience. |
front 36 Which of the following behaviors would be applicable to a nursing diagnosis of Risk for Impaired Parenting? | back 36 Mother states that she feels excessive fatigue as a result of the childbirth experience. |
front 37 A family is concerned about how their 2-year-old son is going to react to the new baby. Which intervention would help facilitate sibling attachment? | back 37 Include the son in helping to take care of the baby and reinforce the label of “big brother” as a special role. |
front 38 The nurse is developing a plan of care for the patient’s fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process? | back 38 Ask the patient if she wants her baby placed on her chest immediately after birth. |
front 39 A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse’s most appropriate response at this time? | back 39 “Are you able to get out of bed and provide care for your baby?” |
front 40 Which vaccinations are indicated for the postpartum patient if she does not have immunity? (Select all that apply.) | back 40 Pertussis Rubella Diphtheria, tetanus (Tdap) Varicella |
front 41 The nurse is planning comfort measures to implement for a patient after a vaginal birth.Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.) | back 41 Sitz baths four times a day Topical anesthetic spray after perineal care Ice pack to the perineum for the first 24 hours |
front 42 The nurse is teaching a non–breastfeeding patient measure to suppress lactation. Which information should the nurse include in the teaching session? (Select all that apply.) | back 42 Avoid massaging the breasts. Ice packs or cabbage leaves can be applied to the breasts to relieve discomfort. Wear a sports bra 24 hours a day until the breasts become soft. |
front 43 The nurse is conducting discharge teaching for a patient going home after a cesarean birth. Which signs and symptoms should the patient be taught to report? (Select all that apply.) | back 43 Feeling of pelvic fullness Frequency, urgency, or burning on urination Redness or edema of the abdominal incision |
front 44 Which of the following are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.) | back 44 Provide comfort and ample time for rest. Position the infant face to face with the mother. Point out the characteristics of the infant in a positive way. |
front 45 Which statement by a postpartum patient indicates that further teaching regarding thrombus formation is unnecessary? | back 45 “I’ll put my support stockings on every morning before rising |
front 46 The nurse understands that late postpartum hemorrhage may be prevented by | back 46 inspecting the placenta after birth. |
front 47 A multiparous patient is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the patient void and massages her fundus; however, the fundus remains difficult to find and the rubra lochia remains heavy which action should the nurse take next | back 47 Notify the health care provider. |
front 48 Early postpartum hemorrhage is defined as a blood loss greater than | back 48 750 mL within 24 hours after a vaginal birth. |
front 49 A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests | back 49 lacerations of the genital tract. |
front 50 A postpartum patient would be at increased risk for postpartum hemorrhage if she delivered a(n) | back 50 6.5-lb infant after a 2-hour labor. |
front 51 The nurse should expect medical intervention for subinvolution to include | back 51 oral methylergonovine maleate (Methergine) for 48 hours. |
front 52 If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition? | back 52 Dilation and curettage (D&C) |
front 53 A positive sign of thrombophlebitis includes | back 53 local tenderness, heat, and swelling. |
front 54 Which nursing measure would be most appropriate to prevent thrombophlebitis in the recovery period following a cesarean birth? | back 54 Assist the patient in performing leg exercises every 2 hours. |
front 55 Which temperature indicates the presence of postpartum infection? | back 55 38.2°C (100.8°F) on the second and third postpartum days |
front 56 A white blood cell (WBC) count of 35,000 cells/mm3 on the morning of the first postpartum day indicates | back 56 possible infection. |
front 57 The patient who is being treated for endometritis is placed in the Fowler position because this position | back 57 facilitates drainage of lochia. |
front 58 Nursing measures that help prevent postpartum urinary tract infection include | back 58 forcing fluids to at least 3000 mL/day. |
front 59 Which measure may prevent mastitis in a breastfeeding patient? | back 59 Initiating early and frequent feedings |
front 60 A patient with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse? | back 60 Organisms that cause mastitis are not passed through the milk. |
front 61 The nurse suspecting a uterine infection in a postpartum patient should assess the | back 61 odor of the lochia. |
front 62 Following a difficult vaginal birth of a singleton pregnancy, the patient starts bleeding heavily. Clots are expressed and a Foley catheter is inserted to empty the bladder because the uterine fundus is soft and displaced laterally from midline. Vital signs are 37.6°C (99.8°F), pulse 90 beats/minute, respirations 20 breaths per minute, and BP 130/90 mm Hg. Which pharmacologic intervention is indicated? | back 62 Administration of prostaglandin analog |
front 63 Following a vaginal birth, a patient has lost a significant amount of blood and is starting to experience signs of hypovolemic shock. Which clinical signs would be consistent with this diagnosis? | back 63 Compensatory response of tachycardia and decreased pulse pressure |
front 64 A patient has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when massaging the fundus . The patient now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to | back 64 initiate a rapid response intervention. |
front 65 A postpartum patient has developed deep vein thrombosis(DVT)stand treatment with warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view of this treatment regimen? | back 65 Lentils |
front 66 To determine an adverse response to carboprost tromethamine (Hemabate), the nurse should frequently assess | back 66 breath sounds. |
front 67 If the nurse suspects a complication of a low forceps birth labor, she should immediately | back 67 assess the perineal and vaginal areas. |
front 68 Prior to ambulating the patient whose admission hemoglobin level was 10.2 g/dL to the bathroom, the nurse should | back 68 dangle her on the side of the bed |
front 69 if a late postpartum hemorrhage is documented on a patient who delivered 3 days ago, the nurse recognizes that this hemorrhage occurred | back 69 on the second postpartum day. |
front 70 Which patient data received during report should the nurse recognize as being at risk for postpartum complications? | back 70 Gravida 5, para 5 |
front 71 Before administering methylergonovine (Methergine), the nurse checks the | back 71 blood pressure. |
front 72 To evaluate the desired response of methylergonovine(Methergine), the nurse would assess the patient’s | back 72 uterine tone. |
front 73 As you receive a report, which assessment finding should you recognize as an indication of a vaginal laceration? | back 73 Bright red continuous trickle of blood from vagina |
front 74 The nurse observes the patient as she ambulates to the bathroom. Which clinical finding might indicate development of a DVT (deep vein thrombosis) | back 74 Stiffness of right leg |
front 75 If a DVT (deep vein thrombosis) is suspected, the nurse should | back 75 place the patient on bed rest, with the affected laegbierble.vcaotmed/.t |
front 76 If the nurse suspects a pulmonary embolism in the patient who suddenly complains of chest pain, she or he should immediately | back 76 apply O2 via tight face mask at 8 to 10 L/minute. |
front 77 To prevent infection of the reproductive tract, the nurse should instruct the patient to | back 77 cleanse the perineum from front to back. |
front 78 The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and 2 cm above the umbilicus. What is the nurse’s priority action? | back 78 Massage the fundus of the uterus. |
front 79 Which information should the nurse recognize as contributing to mastitis in the breastfeeding mother? (Select all that apply.) | back 79 Insufficient emptying Supplementing feedings Blisters on both nipples |
front 80 The visiting nurse must be aware that women who have had a postpartum hemorrhage are subject to a variety of complications after discharge from the hospital. These include which of the following? (Select all that apply.) | back 80 Anemia Exhaustion Postpartum infection Failure to attach to her infant |