1.
The nurse from the nursery is bringing a newborn to a mother’s room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which of the following next to ensure the safest transition of the infant to the mother?■ 1. Assess whether the mother is able to ambu- late to care for the infant.
■ 2. Ask the mother if there is anything else she needs for the care of her baby.
■ 3. Check the crib to determine if there are enough diapers and formula.
■ 4. Complete the hospital identifi cation proce- dure with mother and infant.
2.
A client is in the fi rst hour of her recovery after a vaginal delivery. During an assessment, the lochia is moderate, bright red, and is trickling from the vagina. The nurse locates the fundus at the umbilicus; it is fi rm and midline with no palpable bladder. The client’s vital signs remain at their base- line. Based on this information, the nurse would implement which of the following actions?■ 1. Increase the I.V. rate.
■ 2. Recheck the admission hematocrit and hemo- globin levels.
■ 3. Report the fi ndings to the health care p rovider.
■ 4. Document the fi ndings as normal.
3.
The nurse is caring for a G 3, T 3, P 0, Ab 0, L 3 woman who is one day postpartum following a vaginal delivery. Which of the following indicates a need for further assessment?■ 1. Increased hematocrit and hemoglobin.
■ 2. White blood cell (WBC) count of 15,000.
■ 3. Pulse of 60.
■ 4. Temperature of 100.8° F.
4.
The nurse is caring for a postpartum client who delivered vaginally 4 hours ago and has not voided since delivery. Feeling has returned to her perineal area, and she has ambulated to the bathroom and attempted to void twice. She has ice on her edematous perineum. Her uterus is 3 fi ngerbreadths above the umbilicus, to the right of midline, and fi rm only with massage. What is the priority nursing action?■ 1. Evaluate the client with a bladder scan.
■ 2. Insert a Foley catheter.
■ 3. Medicate the client with a nonsteroidal anti- infl ammatory drug (NSAID).
■ 4. Massage the fundus until it is fi rm and per- form a one-time catheterization on the client.
5.
A client delivered vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous and the client is complaining of pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?■ 1. Begin sitz baths.
■ 2. Administer pain medication per order.
■ 3. Replace ice packs to the perineum.
■ 4. Initiate anesthetic sprays to the perineum.
6.
A client is in the fourth stage of labor. Which set of assessments is the highest priority at this time?■ 1. Assessment of the ability to push with con- tractions, hydration, and emotional stability.
■ 2. Assessment of maternal vital signs, fetal heart tones, and the contraction pattern.
■ 3. Assessment of maternal vital signs, the fun- dus, the bladder, and lochia.
■ 4. Assessment of maternal emotional status, infant bonding, and feeding preferences.
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7.
A primigravid client delivered vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpar- tum goal would have the highest priority?■ 1. By discharge, the family will bond with the neonate.
■ 2. The client will demonstrate self-care and infant care by the end of the shift.
■ 3. The client will state instructions for discharge during the fi rst postpartum day.
■ 4. By the end of the shift, the client will describe a safe home environment.
8.
In response to the nurse’s question about how she is feeling, a postpartum client states that she is fi ne. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?■ 1. Taking in.
■ 2. Taking on.
■ 3. Taking hold.
■ 4. Letting go.
9.
A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which of the following actions in the infant’s plan of care?■ 1. Urine toxicology screening.
■ 2. Notifying hospital security.
■ 3. Limiting contact with visitors.
■ 4. Contacting local law enforcement.
10.
The nurse is evaluating the client who delivered vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The cli- ent is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus.Which of the medications listed on the orders sheet would be the most appropriate for this client?
■ 1. Aspirin 1,000 mg P.O. q 4 to 6 hour p.r.n.
■ 2. Ibuprofen 800 mg P.O. q 6 to 8 hour p.r.n.
■ 3. Colace 100 mg P.O. b.i.d.
■ 4. Vicodin 1 to 2 tabs P.O. q 4 to 6 hour p.r.n.
11.
At which of the following locations would the nurse expect to palpate the fundus of a primipa- rous client immediately after delivery of a neonate?■ 1. Halfway between the umbilicus and the sym- physis pubis.
■ 2. At the level of the umbilicus.
■ 3. Just below the level of the umbilicus.
■ 4. Above the level of the umbilicus.
12.
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following?■ 1. Chorioretinitis from cytomegalovirus.
■ 2. Blindness secondary to gonorrhea.
■ 3. Cataracts from beta-hemolytic streptococcus.
■ 4. Strabismus resulting from neonatal maturation.
13.
The physician orders an intramuscular injection of phytonadione (AquaMEPHYTON) for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following?■ 1. Hypoglycemia.
■ 2. Hyperbilirubinemia.
■ 3. Hemorrhage.
■ 4. Polycythemia.
14.
When developing the plan of care for a primiparous client during the fi rst 12 hours after vaginal delivery, which of the following concerns of the client should be the nurse’s primary focus of care?■ 1. The neonate.
■ 2. The family.
■ 3. The client’s own comfort.
■ 4. The client’s signifi cant other.
15.
The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal delivery. The nurse should next:■ 1. Apply an ice pack to the perineal area.
■ 2. Assess the client’s temperature.
■ 3. Have the client take a warm sitz bath.
■ 4. Contact the physician for orders for an antibiotic.
16.
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the cli- ent with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client’s bladder, fi nding it distended. The nurse interprets this fi nding based on the understanding that the client’s bladder distention is most likely caused by which of the following?■ 1. Prolonged fi rst stage of labor.
■ 2. Urinary tract infection.
■ 3. Pressure of the uterus on the bladder.
■ 4. Edema in the lower urinary tract area.
17.
A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse,“When will my menstrual cycle return?” Which of the following responses by the nurse would be most appropriate?
■ 1. “Your menstrual cycle will return in 3 to 4 weeks.”
■ 2. “It will probably be 6 to 10 weeks before it starts again.”
■ 3. “You can expect your menses to start in 12 to 14 weeks.”
■ 4. “Your menses will return in 16 to 18 weeks.”
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23.
After explaining the procedure for using a portable sitz bath to a primiparous client who deliv- ered 30 hours ago, which of the following would the nurse do next?■ 1. Fill the collecting bag with water at a tem- perature of 107° F (41.25° C).
■ 2. Spray the perineal area with the ordered anal- gesic spray.
■ 3. Wash hands and don clean gloves for the procedure.
■ 4. Assess the client’s perineum for swelling and redness.
24.
A primiparous client, 20 hours after delivery, asks the nurse about starting postpartum exercises.Which of the following would be most appropriate to include in the nurse’s instructions?
■ 1. Start in a sitting position, then lie back, and return to a sitting position, repeating this fi ve times.
■ 2. Assume a prone position, then do push-ups by using the arms to lift the upper body.
■ 3. Flex the knees while supine, then inhale deeply and exhale while contracting the abdominal muscles.
■ 4. Flex the knees while supine, then bring chin to chest while exhaling and reach for the knees by lifting the head and shoulders while inhaling.
25.
A multiparous client whose fundus is fi rm and midline at the umbilicus 8 hours after a vagi- nal delivery tells the nurse that when she ambu- lated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explain- ing to the client about the increased lochia on ambulation?■ 1. Her bleeding needs to be reported to the phy- sician immediately.
■ 2. The increased lochia occurs from lochia pool- ing in the vaginal vault.
■ 3. The increase in lochia may be an early sign of postpartum hemorrhage.
■ 4. This increase in lochia usually indicates retained placental fragments.
26.
Four hours after delivering a viable neonate by spontaneous vaginal delivery under epidural anesthesia, the client states she needs to urinate.The nurse should next:
■ 1. Catheterize the client to obtain an accurate measurement.
■ 2. Palpate the bladder to determine distention.
■ 3. Assess the fundus to see if it is at the midline.
■ 4. Measure the fi rst two voidings and record the amount.
18.
While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following?■ 1. Effects of the anesthetic during labor.
■ 2. Hemorrhage during the delivery process.
■ 3. Effects of analgesics used during labor.
■ 4. Decreased blood volume in the vascular system.
19.
The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico who speaks very little English and delivered a viable term neonate 8 hours ago. When developing the postpartum dietary plan of care for the client, the nurse would encourage the client’s intake of which of the following?■ 1. Tomatoes.
■ 2. Potatoes.
■ 3. Corn products.
■ 4. Meat products.
20.
Three hours postpartum, a primiparous client’s fundus is fi rm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which of the following conditions should the nurse assess further?■ 1. Retained placental tissue.
■ 2. Uterine inversion.
■ 3. Bladder distention.
■ 4. Perineal lacerations.
21.
At a postpartum check up 11 days after delivery, the nurse asks the client about the color of her lochia. Which of the following colors is expected?■ 1. Dark red.
■ 2. Pink.
■ 3. Brown.
■ 4. White.
22.
After instructing a primiparous client about episiotomy care, which of the following client state- ments indicates successful teaching?■ 1. “I’ll use hot, sudsy water to clean the epi- siotomy area.”
■ 2. “I wipe the area from front to back using a blotting motion.”
■ 3. “Before bedtime, I’ll use a cold water sitz bath.”
■ 4. “I can use ice packs for 3 to 4 days after delivery.”
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32.
The nurse on the night shift fi nds a mul- tiparous client, 8 hours postpartum, drenched in perspiration. The client’s temperature is 99° F (36.8° C), the pulse is 68 bpm, and the blood pres- sure is 120/80 mm Hg. Which of the following nurs- ing diagnoses is a priority?■ 1. Risk for infection (postpartum) related to birth trauma.
■ 2. Ineffective thermoregulation related to hor- monal changes.
■ 3. Ineffective tissue perfusion: Renal related to the status of multiparity.
■ 4. Excess fl uid volume related to normal post- partal diuresis.
33.
On the fi rst postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the cli- ent for:■ 1. Puerperal infection.
■ 2. Vaginal lacerations.
■ 3. History of drug abuse.
■ 4. Perineal hematoma.
34.
The nurse assigns an individual who is an unlicensed assistive personnel to care for a client who is one day postpartum. Which of the follow- ing would be appropriate to delegate to this person?Select all that apply.
■ 1. Changing the perineal pad and reporting the drainage.
■ 2. Assisting the mother to latch the infant onto the breast.
■ 3. Checking the location of the fundus prior to ambulating the client.
■ 4. Reinforcing good hygiene while assisting the client with washing the perineum.
■ 5. Discussing postpartum depression with the client who is found crying.
■ 6. Assisting the client with ambulation shortly after delivery.
35.
While the nurse is caring for a primiparous client on the fi rst postpartum day, the client asks,“How is that woman doing who lost her baby from prematurity? We were in labor together.” Which of the following responses by the nurse would be most appropriate?
■ 1. Ignore the client’s question and continue with morning care.
■ 2. Tell the client “I’m not sure how the other woman is doing today.”
■ 3. Tell the client “I need to ask the woman’s permission before discussing her well-being.”
■ 4. Explain to the client that “Nurses are not allowed to discuss other clients on the unit.”
27.
A primiparous client who delivered vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which of the following?■ 1. Fatigue.
■ 2. Fainting.
■ 3. Diuresis.
■ 4. Hygiene needs.
28.
A primiparous client who delivered 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate?■ 1. “Ask for some pain medication before you sit down.”
■ 2. “Squeeze your buttock muscles together before sitting down.”
■ 3. “Keep a relaxed posture before sitting down with your full weight.”
■ 4. “Ask the physician for some analgesic cream or spray.”
29.
Which of the following would the nurse include in the primiparous client’s discharge teach- ing plan about measures to provide visual stimula- tion for the neonate?■ 1. Maintain eye contact while talking to the baby.
■ 2. Paint the baby’s room in bright colors accented with teddy bears.
■ 3. Use brightly colored animals and cartoon fi gures on the wall.
■ 4. Move a brightly colored rattle in front of the baby’s eyes.
30.
A primiparous client has just delivered a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse inter- prets the father’s actions as indicative of which of the following?■ 1. Thanking Allah for giving him a male heir.
■ 2. Singing to his son from the Koran in praise of Allah.
■ 3. Expressing appreciation that his wife and son are healthy.
■ 4. Performing a ritual similar to baptism in other religions.
31.
An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without “spoiling” him. Which of the fol- lowing responses would be most appropriate?■ 1. “Hold him when he is fussy or crying.”
■ 2. “Hold him as much as you want to hold him.”
■ 3. “Try to hold him infrequently to avoid over- stimulation.”
■ 4. “You can hold him periodically throughout the day.”
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41.
An adolescent primiparous client at 24 hours postpartum tells the nurse that she and her baby will be living with her boyfriend’s parents so that she can fi nish high school and go on to col- lege. The client’s boyfriend and parents have been supportive of the client and neonate. Which of the following is an appropriate nursing diagnosis at this time?■ 1. Anxiety related to return to high school and peer pressure.
■ 2. Ineffective coping related to inability to view motherhood realistically.
■ 3. Readiness for enhanced family coping, related to the addition of a new family member.
■ 4. Defi cient knowledge related to the fi nancial and emotional costs of childrearing.
42.
A primiparous client who delivered a viable term neonate vaginally 48 hours ago has a mid- line episiotomy and repair of a third-degree lac- eration. When preparing the client for discharge, which of the following assessments would be most important?■ 1. Constipation.
■ 2. Diarrhea.
■ 3. Excessive bleeding.
■ 4. Rectal fi stulas.
43.
In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal delivery with a midline episiotomy. The nurse should instruct the client that she can resume sexual intercourse:■ 1. In 6 weeks when the episiotomy is com- pletely healed.
■ 2. After a postpartum check by the health care provider.
■ 3. Whenever the client is feeling amorous and desirable.
■ 4. When lochia fl ow and episiotomy pain have stopped.
44.
The physician orders docusate sodium (Colace) 100 mg at bedtime for a primiparous cli- ent after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?■ 1. Relief from episiotomy pain.
■ 2. Contraction of the uterus.
■ 3. Softening of the stool.
■ 4. Aid in sleeping.
36.
A newly delivered primiparous client asks the nurse, “Can my baby see?” Which of the fol- lowing statements about neonatal vision should the nurse include in the explanation?■ 1. Neonates primarily focus on moving objects.
■ 2. They can see objects up to 12 inches away.
■ 3. Usually they see clearly by about 2 days after birth.
■ 4. Neonates primarily distinguish light from dark.
37.
While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles.The nurse should tell the client:
■ 1. She will have a surgical repair at 6 weeks postpartum.
■ 2. To remain on bed rest until resolution occurs.
■ 3. The separation will resolve on its own with the right posture and diet.
■ 4. To perform exercises involving head and shoulder raising in a lying position.
38.
A postpartum client delivered 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus 2 fi ngerbreadths above the umbilicus and off to the right side. What should the nurse do fi rst?■ 1. Administer ibuprofen (Motrin).
■ 2. Reassess in 1 hour.
■ 3. Catheterize the client.
■ 4. Administer an I.V. bolus of 500 mL to rehy- drate per policy.
39.
While the nurse is assessing the fundus of a multiparous client who delivered 24 hours ago, the client asks, “What can I do to get rid of these stretch marks?” Which of the following responses would be most appropriate?■ 1. “As long as you don’t get pregnant again, the marks will disappear completely.”
■ 2. “They usually fade to a silvery-white color over a period of time.”
■ 3. “You’ll need to use a specially prescribed cream to help them disappear.”
■ 4. “If you lose the weight you gained during pregnancy, the marks will fade to a pale pink.”
40.
A primiparous client who delivered a viable neonate 8 hours ago tells the nurse that she gained 26 lb during pregnancy and asks how long it will take to return to her normal prepreg- nant weight. The nurse should tell the client that the usual time frame for returning to prepregnant weight is:■ 1. 4 weeks.
■ 2. 6 weeks.
■ 3. 8 weeks.
■ 4. 12 weeks.
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49.
The nurse is completing discharge instruc- tions with a new mother and is concerned about her safety. Which statement by the client indicates the client needs further instructions?■ 1. “I will need to be checked out by the doctor in a week.”
■ 2. “I need to wear a sports bra for a few days so I don’t get milk.”
■ 3. “I can get pregnant now if I don’t use birth control.”
■ 4. “I may feel sad for a few days but should be OK within a few days.”
50.
The nurse is caring for a multiparous client after vaginal delivery of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to:■ 1. Bottle-feed the twins to prevent exhaustion and fatigue.
■ 2. Plan for each parent to spend equal amounts of time with each twin.
■ 3. Avoid assistance from other family members until attachment occurs.
■ 4. Relate to each twin individually to enhance the attachment process.
51.
Twelve hours after a vaginal delivery with epidural anesthesia, the nurse palpates the fundus of a primiparous client and fi nds it to be fi rm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next?■ 1. Document this as a normal fi nding in the cli- ent’s record.
■ 2. Contact the physician for an order for methyl- ergonovine.
■ 3. Encourage the client to ambulate to the bath- room and void.
■ 4. Gently massage the fundus to expel the clots.
52.
A nurse is discussing discharge instructions with a client. Which of the following statements indicate that the client understands the resources and information available if needed after discharge?Select all that apply.
■ 1. “I know to wait 2 weeks before I start my birth control pills.”
■ 2. “I have the hospital phone number if I have any questions.”
■ 3. “If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medi- cal assistance.”
■ 4. “My mother is coming to help for a month so I will be fi ne.”
■ 5. “I know if I get fever or chills or change in lochia to call the physician.”
■ 6. “I will continue my prenatal vitamins until my postpartum checkup or longer.”
45.
While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother’s temperature is 99.8° F (37.2° C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is fi rm, mid- line, and at the level of the umbilicus. The nurse should:■ 1. Continue to monitor the client’s vital signs.
■ 2. Assess the client’s lochia for large clots.
■ 3. Notify the client’s physician about the fi ndings.
■ 4. Offer the mother an ice pack for her forehead.
46.
While assessing the episiotomy site of a primiparous client on the fi rst postpartum day, the nurse observes a fairly large hemorrhoid at the client’s rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which of the following client statements indicates the need for additional teaching?■ 1. “I should try to gently manually replace the hemorrhoid.”
■ 2. “Analgesic sprays and witch hazel pads can relieve the pain.”
■ 3. “I should lie on my back as much as possible to relieve the pain.”
■ 4. “I should drink lots of water and eat foods that have a lot of roughage.”
47.
A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks little English. The client’s mother asks the nurse if she can bring her daughter some“special foods from home.” The nurse responds, based on the understanding about which of the following?
■ 1. Foods from home are generally discouraged on the postpartum unit.
■ 2. The mother can bring the daughter any foods that she desires.
■ 3. This is permissible as long as the foods are nutritious and high in iron.
■ 4. The client’s physician needs to give permis- sion for the foods.
48.
A primiparous client, 48 hours after a vagi- nal delivery, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following?■ 1. Orange juice.
■ 2. Herbal tea.
■ 3. Milk.
■ 4. Grape juice.
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