97.
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.What action should the nurse take based on this assessment?
■ 1. Notify the health care provider of the separa- tion.
■ 2. Discuss with the client that no further action is needed.
■ 3. Demonstrate exercises involving head and shoulder lifting.
■ 4. Refer the client to a surgeon for surgical repair after 6 weeks postpartum.
98.
A multiparous client at 24 hours postpartum demonstrates a positive Homan’s sign with discom- fort. The nurse should:■ 1. Place a cold pack on the client’s perineal area.
■ 2. Place the client in a semi-Fowler’s position.
■ 3. Notify the client’s physician immediately.
■ 4. Ask the client to ambulate around the room.
90.
Carboprost (Hemabate) was injected into the uterus of a client to treat uterine atony during a cesarean section. In preparing to care for this client postpartum, the nurse should assess the client for which of the following common adverse effects of the medication?■ 1. Vertigo and confusion.
■ 2. Nausea and diarrhea.
■ 3. Restlessness and increased vaginal bleeding.
■ 4. Headache and hypertension.
91.
A 30-year-old woman, G 4, P 4, has delivered a healthy term female neonate by cesarean delivery due to a nonreassuring fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client’s retention catheter and observes that the client’s urine is slightly red tinged. Which of the following should the nurse do next?■ 1. Continue to monitor the client’s input and output.
■ 2. Palpate the client’s fundus gently every 15 minutes.
■ 3. Assess the placement of the retention cath- eter.
■ 4. Contact the client’s physician for further orders.
92.
While changing the neonate’s diaper, the cli- ent asks the nurse about some red-tinged drainage from the neonate’s vagina. Which of the following responses would be most appropriate?■ 1. “It’s of no concern because it is such a small amount.”
■ 2. “The cause is usually related to swallowing blood during the delivery.”
■ 3. “Sometimes baby girls have this from hor- mones received from the mother.”
■ 4. “This vaginal spotting is caused by hemor- rhagic disease of the newborn.”
93.
Four hours after cesarean delivery of a neo- nate weighing 4,000 g (8 lb, 13 oz), the primiparous client asks, “If I get pregnant again, will I need to have a cesarean?” When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean delivery (VBAC) on which of the following?■ 1. VBAC may be possible if the client has not had a classic uterine incision.
■ 2. A history of rapid labor is a necessary crite- rion for VBAC.
■ 3. A low transverse incision contraindicates the possibility for VBAC.
■ 4. VBAC is not possible because the neonate was large for gestational age.
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104.
A postpartum multiparous client diagnosed with endometritis is to receive intravenous antibi- otic therapy with ampicillin sodium (Polycillin).Before administering this drug, the nurse must do which of the following?
■ 1. Ask the client if she has any drug allergies.
■ 2. Assess the client’s pulse rate.
■ 3. Place the client in a side-lying position.
■ 4. Check the client’s perineal pad.
105.
Which of the following would be most impor- tant for the nurse to encourage in a primiparous client diagnosed with endometritis who is receiving intravenous antibiotic therapy?■ 1. Ambulate to the bathroom frequently.
■ 2. Discontinue breast-feeding temporarily.
■ 3. Maintain bed rest in Fowler’s position.
■ 4. Restrict visitors to prevent contamination.
106.
Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who delivered 24 hours ago and is receiving intravenous antibiotic therapy for cystitis?■ 1. Limiting fl uid intake to 1 L daily to prevent overload.
■ 2. Emptying the bladder every 2 to 4 hours while awake.
■ 3. Washing the perineum with povidone iodine (Betadine) after voiding.
■ 4. Avoiding the intake of acidic fruit juices until the treatment is discontinued.
107.
A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intrave- nous ampicillin asks the nurse, “Can I still continue to breast-feed my baby?” The nurse should tell the client:■ 1. “You can continue to breast-feed as long as you want to do so.”
■ 2. “Alternate your breast-feeding with formula feeding to help you rest.”
■ 3. “You’ll need to discontinue breast-feeding until the antibiotic therapy is stopped.”
■ 4. “You’ll need to modify your technique by manually pumping your breasts.”
108.
Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergon- ovine maleate (Methergine), 0.2 mg intramuscularly.Before administering this drug, the nurse should assess:
■ 1. Blood pressure.
■ 2. Pulse rate.
■ 3. Breath sounds.
■ 4. Bowel sounds.
99.
Prophylactic heparin therapy is ordered to treat thrombophlebitis in a multiparous client who delivered 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which of the following as the purpose of the drug?■ 1. To thin the blood clots.
■ 2. To increase the lochial fl ow.
■ 3. To increase the perspiration for diuresis.
■ 4. To prevent further blood clot formation.
100.
While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the cli- ent’s physician immediately if the client exhibited which of the following?■ 1. Pain in her calf.
■ 2. Dyspnea.
■ 3. Hypertension.
■ 4. Bradycardia.
101.
A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states that the adverse effects include which of the following?■ 1. Epistaxis.
■ 2. Bleeding gums.
■ 3. Slow pulse.
■ 4. Petechiae.
102.
After being treated with heparin therapy for thrombophlebitis, a multiparous client who deliv- ered 4 days ago is to be discharged on oral war- farin (Coumadin). After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching?■ 1. “I can take two aspirin if I get uterine cramps.”
■ 2. “Protamine sulfate should be available if I need it.”
■ 3. “I should use a soft toothbrush to brush my teeth.”
■ 4. “I can drink an occasional glass of wine if I desire.”
103.
A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory track infection following delivery. The nurse determines the client understands principles of infection control to follow when the client says:■ 1. “I must use barrier isolation.”
■ 2. “I must wear a gown and gloves.”
■ 3. “I must use individual client care equip- ment.”
■ 4. “I must practice frequent hand washing.”
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114.
A primiparous client who had a vaginal delivery 1 hour ago voices anxiety because she has a nephew with Down syndrome. After teaching the client about Down syndrome, which of the following client state- ments indicates the need for additional teaching?■ 1. “Down syndrome is an abnormality that can result from a missing chromosome.”
■ 2. “Down syndrome usually results in some degree of mental retardation.”
■ 3. “There are several methods available to deter- mine whether my baby has Down syndrome.”
■ 4. “Older mothers are more likely to have a baby with chromosomal abnormalities.”
115.
A 15-year-old unmarried primiparous client is being cared for in the hospital’s birthing center after vaginal delivery of a viable neonate. The neo- nate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which of the following responses would be most appropriate?■ 1. “I’ll bring the baby to you for feeding.”
■ 2. “I think we should ask your physician if this is a good idea.”
■ 3. “It’s not a good idea for you to have any con- tact with the baby.”
■ 4. “I’ll check with the social worker to see if the adopting parents will permit this.”
116.
After teaching a primiparous client about treat- ment and self-care of infectious mastitis of the right breast, the nurse determines that the client needs fur- ther instruction when she states which of the following?■ 1. “I can apply localized heat to the infected area.”
■ 2. “I should increase my fl uid intake to 2,000 mL per day.”
■ 3. “I’ll need to take antibiotics for 7 to 10 days before I am cured.”
■ 4. “I should begin breast-feeding on the right side to decrease the pain.”
117.
During a home visit to a primiparous client who delivered vaginally 14 days ago, the client says,“I’ve been crying a lot the last few days. I just feel so awful. I am a rotten mother. I just don’t have any energy. Plus, my husband just got laid off from his job.” The nurse observes that the client’s appearance is disheveled. Which of the following would be the nurse’s best response?
■ 1. “These feelings commonly indicate symptoms of postpartum blues and are normal. They’ll go away in a few days.”
■ 2. “I think you’re probably overreacting to the labor and delivery process. You’re doing the best you can as a mother.”
■ 3. “It’s not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your doctor.”
■ 4. “This may be a symptom of a serious mental illness. I think you should probably go to the hospital.”
109.
During the fi rst hour after delivery, assessment of a multiparous client who delivered a neonate weighing 4,593 g (10 lb, 2 oz) by cesarean delivery reveals a soft fundus with excessive lochia rubra.The nurse should include which of the following in the client’s plan of care?
■ 1. Administration of intravenous oxytocin.
■ 2. Placement of the client in a side-lying position.
■ 3. Rigorous fundal massage every 5 minutes.
■ 4. Preparation for an emergency hysteromyo- mectomy.
110.
A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hem- orrhage at 1 hour after a cesarean delivery. The cli- ent asks, “Why am I bleeding so much?” The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which of the following?■ 1. Trauma during labor and delivery.
■ 2. Moderate fundal massage after delivery.
■ 3. Lengthy and prolonged second stage of labor.
■ 4. Overdistention of the uterus from hydramnios.
111.
Thirty-six hours after a vaginal delivery, a multiparous client is diagnosed with endometritis due to b-hemolytic streptococcus. When assessing the client, which of the following would the nurse expect to fi nd?■ 1. Profuse amounts of lochia.
■ 2. Abdominal distention.
■ 3. Nausea and vomiting.
■ 4. Odorless vaginal discharge.
112.
A multiparous client visits the urgent care center 5 days after a vaginal delivery experienc- ing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, “Why am I con- tinuing to bleed like this?” The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following?■ 1. Uterine atony.
■ 2. Cervical lacerations.
■ 3. Vaginal lacerations.
■ 4. Retained placental fragments.
113.
A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after delivering a viable female neonate. The client, who is breast-feeding, is diagnosed with infectious mastitis of the right breast.The client asks the nurse, “Can I continue breast- feeding?” The nurse should tell the client:
■ 1. “You can continue to breast-feed, feeding your baby more frequently.”
■ 2. “You can continue once your symptoms begin to decrease.”
■ 3. “You must discontinue breast-feeding until antibiotic therapy is completed.”
■ 4. “You must stop breast-feeding because the breast is contaminated.”
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120.
The nurse on a mother-baby unit who is working on the night shift is revising the planning worksheet for the remaining 2 hours of the shift.The nurse has the following tasks and orders to complete prior to the 7 a.m. change of shift. Using the work plan below, how should the nurse organize the following tasks so that everything is completed by 7 a.m.?
■ 1. Draw blood for the ordered laboratory tests (CBCs) on 3 postpartum clients with report on charts by shift change.
■ 2. Start IV of D5 ½ NS at keep vein open (KVO) rate on postpartum client just prior to change of shift.
■ 3. Complete admission assessment of newborn turned over to nurse at 5 a.m.
■ 4. Draw newborn bilirubin level at 6 a.m.
Nurse Worksheet
5:00 5:30 6:00 6:30
121.
The nurse on the postpartum mother-baby unit is assigned to take care of four couplets and a new couplet will be admitted within the next 30 minutes. All assessments are complete. The nurse can delegate care for which couplet to the unli- censed nursing personnel?■ 1. A G1 P1 with gestational diabetes who is 12 hours postpartum and who still requires insulin.
■ 2. A G4 P4 who is breast-feeding an 8 lb infant without diffi culty.
■ 3. A G3 P3 postpartum client who is receiving Magnesium Sulfate and whose infant has a respiratory rate of 20.
■ 4. A G2 P2 who delivered vaginally 2 days ago with an infant having low blood glucose lev- els the fi rst 24 hours post delivery.
Managing Care Quality and Safety
118.
The nurse is catheterizing a client who can- not void after a normal delivery 8 hours ago. The nurse begins the catheterization process and the cli- ent asks the nurse if Betadine was used to clean the meatus for the catheterization. The nurse realizes that the client is allergic to Betadine and the client is reacting to the cleansing agent. The nurse should take the following steps in order of priority from fi rst to last.2. Clean Betadine from client’s vaginal area.
3. Notify physician ordering catheterization.
5. File an incident report.
4. Ask client what her reaction is when exposed to Betadine.
1. Document incident.
119.
A nurse is walking down the hall in the main corridor of a hospital. The Code Pink infant security alert system sounds and a Code Pink alert is announced. The fi rst responsibility of the nurse when this situation occurs is to do which of the fol- lowing?■ 1. Move to the entrance of the hospital and check each person leaving.
■ 2. Go to the obstetrics unit to determine if they need help with the situation.
■ 3. Call the nursery to ask which baby is missing.
■ 4. Observe individuals in the area for large bags or oversized coats.
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3.
4. Within the fi rst 24 hours postpartum, the maternal temperature may increase to 100.4°F, a normal postpartum fi nding attributed to dehydra- tion. A temperature higher than 100.4°F after the fi rst 24 hours indicates a potential for infection.Hemoconcentration is a normal fi nding postpartum due to the remobilization and rapid loss of excess body fl uids. WBC count is normally elevated as a response to the infl ammation, pain, and stress of the birthing process. A pulse rate of 60 bpm is normal at this period and results from an increased cardiac output (mobilization of excess extracellular fl uid into the vascular bed, decreased pressure from the uterus on vessels, blood fl ow back to the heart from the uterus returning to the central circulation) and alteration in stroke volume.
CN: Physiological adaptation;
CL: Analyze
4.
4. Uterine massage enables immediate con- traction of the uterus to prevent bleeding. In-and-out catheterization relieves bladder distention, elimi- nates displacement, fi rms the uterus, and prevents uterine bleeding. A bladder scan is not necessary because the nurse is able to palpate the full bladder.The positioning of the uterus indicates a full blad- der. An indwelling urinary catheter is not necessary because most clients spontaneously void within 12 hours. The use of an NSAID will help reduce the infl ammation that may be present but its action is not immediate and the status of the fundus needs more immediate interventions because of the risk of postpartum hemorrhage associated with a full blad- der.
CN: Management of care; CL: Synthesize
5.
2. Pain medication is the fi rst strategy to initi- ate at this pain level. When trauma has occurred to any area, the usual intervention is ice for the fi rst 24 hours and heat after the fi rst 24 hours. Sitz baths are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays can also be utilized for the perineal area when pain is involved but would not lower the pain to a level that the client considers tolerable.CN: Physiological adaptation;
CL: Synthesize
6.
3. Stage four is the fi rst 2 to 4 hours postpar- tum. At this time, the nurse should frequently assess maternal vital signs, the fundus, bladder status, and lochia. The vital signs indicate the ability of the client to transition from pregnancy to postpartum and the physical status of the mother. The mater- nal fundus should remain fi rm, midline, and at the umbilicus or lower. A bladder that is distendedAnswers, Rationales, and Test Taking Strategies
The answers and rationales for each question follow below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills.
For additional information about test-taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book.