Exam 3 - Extra Questions

Question 1

a nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. the pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. which of the following findings should the nurse document?

a) moderate lochia rubra
b) excessive lochia serosa
c) light lochia rubra
d) scant lochia serosa

Answer 1

a

the client has moderate lochia rubra containing small clots, which is an expected finding for the second day postpartum.

Question 2

during ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. on assessment, the nurse finds the uterus to be firm, midline, and at the level of the umbilicus. which of the following findings should the nurse interpret this data as being?

a) evidence of a possible vaginal hematoma
b) an indication of a cervical or perineal laceration
c) a normal postural discharge of lochia
d) abnormally excessive lochia rubra flow

Answer 2

c

lochia typically trickles from the vaginal opening but flows more steadily during uterine contractions. massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease back to a trickle of bright red lochia in the early puerperium.

Question 3

a nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. which of the following statements by the client indicates understanding of the teaching?

a) “i will need to use contraception for 3 months before considering pregnancy.”
b) “i need a second vaccination at my postpartum visit.”
c) “i was given the vaccine because my baby is O-positive.”
d) “i will be tested in 3 months to see if i have developed immunity.”

Answer 3

b

a second varicella immunization is needed 4 to 8 weeks following delivery by clients who had no history of immunity.

Question 4

a nurse is assessing a postpartum client for fundal height, location, and consistency. the fundus is noted to be displaced laterally to the right, and there is uterine atony. the nurse should identify which of the following conditions as the cause of the uterine atony?

a) poor involution
b) urinary retention
c) hemorrhage
d) infection

Answer 4

b

urinary retention can result in a distention of the bladder. a distended bladder can cause uterine atony and lateral displacement from the midline.

Question 5

a nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. which of the following information should the nurse include? (select all that apply.)

a) use a perineal squeeze bottle to cleanse the perineum.
b) sit on the perineum while resting in bed.
c) apply a topical anesthetic cream or spray to the perineum.
d) wipe the perineum thoroughly with and back-and-forth motion.
e) apply cold or ice packs to the perineum.

Answer 5

a, c, e

use a perineal squeeze bottle filled with warm water to cleanse the perineum and promote healing. the application of a topical anesthetic cream or spray to the perineum will promote comfort. the application of cold or ice packs to the perineum will promote comfort and decrease swelling.

Question 6

a nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. the parent appears very anxious and nervous when asked to bring the newborn to the other parent. which of the following actions should the nurse use to promote parent-infant bonding?

a) hand the parent the newborn, and suggest that they change the diaper.
b) ask the parent why they are so anxious and nervous.
c) tell the parent that they will grow accustomed to the newborn.
d) provide education about infant care when the parent is present.

Answer 6

d

nursing interventions to promote paternal bonding include providing education about newborn care and encouraging the parent to take a hands-on approach.

Question 7

a client in the early postpartum period is very excited and talkative. they repeatedly tell the nurse every detail of the labor and birth. because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. which of the following actions should the nurse take?

a) come back later when the client is more cooperative.
b) give the client time to express feelings.
c) tell the client they need to be quiet so the assessment can be completed.
d) redirect the client’s focus so that they will become quiet.

Answer 7

b

recognize that the client is in the taking-in phase, which begins immediately following birth and lasts a few hours to a couple of day

Question 8

a nurse is caring for a client who is 1 day postpartum. the nurse is assessing for maternal adaptation and parent-infant bonding. which of the following behaviors by the client indicates a need for the nurse to intervene? (select all that apply.)

a) demonstrates apathy when the newborn cries
b) touches the newborn and maintains close physical proximity
c) views the newborn’s behavior as uncooperative during diaper changing
d) identifies and relates newborn’s characteristics to those of family members
e) interprets the newborn’s behavior as meaningful and a way of expressing needs

Answer 8

a, c
this behavior demonstrates a lack of interest in the newborn and impaired parent-infant bonding. a client’s view of their newborn as being uncooperative during diaper changing is a sign of impaired parent-infant bonding.

Question 9

a nurse is caring for a client who is 2 days postpartum. the client states, “my 4-year-old son was toilet trained and now he is frequently wetting himself.” which of the following statements should the nurse provide to the client?

a) “your son was probably not ready for toilet training and should wear training pants.”
b) “your son is showing an adverse sibling response.”
c) “your son may need counseling.”
d) “you should try sending your son to preschool to resolve the behavior.”

Answer 9

b

adverse responses by a sibling to a new infant can include regression in toileting habits.

Question 10

a nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. which of the following is the priority action by the nurse?

a) encourage the parents to touch and explore the neonate’s features.
b) limit noise and interruption in the delivery room.
c) place the neonate at the client’s breast.
d) position the neonate skin-to-skin on the client’s chest.

Answer 10

d
placing the neonate in the en face position on the client’s chest immediately after birth is the priority nursing intervention to promote parent-infant bonding.

Question 11

a nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. the client reports breast engorgement. which of the following recommendations should the nurse make?

a) “apply cold compresses between feedings.”
b) “take a warm shower right after feedings.”
c) “apply breast milk to the nipples and allow them to air dry.”
d) “use the various infant positions for feedings.”

Answer 11

a

cold compresses applied to the breasts after the feeding can help with breast engorgement.

Question 12

a nurse is providing discharge instructions for a client. at 4 weeks postpartum, the client should contact the provider for which of the following client findings?

a) scant, nonodorous white vaginal discharge
b) uterine cramping during breastfeeding
c) sore nipple with cracks and fissures
d) decreased response with sexual activity

Answer 12

c

a sore nipple that has cracks and fissures is an indication of mastitis.

Question 13

a nurse is providing discharge teaching for a nonlactating client. which of the following instructions should the nurse include in the teaching?

a) “wear a supportive bra continuously for the first 72 hours.”
b) “pump your breasts every 4 hours to relieve discomfort.”
c) “use breast shells throughout the day to decrease milk supply.”
d) “apply warm compresses until milk suppression occurs.”

Answer 13

a

instruct the client to wear a well-fitting support bra continuously for the first 72 hr.

Question 14

a nurse is providing discharge instructions to a postpartum client following a cesarean birth. the client reports leaking urine every time they sneeze or cough. which of the following interventions should the nurse suggest?

a) sit-ups
b) pelvic tilt exercises
c) kegel exercises
d) abdominal crunches

Answer 14

c
kegel exercises consist of the voluntary contraction and relaxation of the pubococcygeus muscle to strengthen the pelvic muscles, which will assist the client in decreasing urinary stress incontinence that occurs with sneezing and coughing.

Question 15

a nurse is providing care to four clients on the postpartum unit. which of the following clients is at greatest risk for developing a postpartum infection?

a) a client who has an episiotomy that is erythematous and has extended into a third-degree laceration
b) a client who does not wash their hands between perineal care and breastfeeding
c) a client who is not breastfeeding and is using measures to suppress lactation
d) a client who has a cesarean incision that is well-approximated with no drainage

Answer 15

b
the client who does not wash their hands between perineal care and breastfeeding is at an increased risk for developing mastitis. therefore, they are most at risk for developing a postpartum infection.

Question 16

a nurse is caring for a client who is postpartum. the nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage?

a) increasing pulse and decreasing blood pressure
b) dizziness and increasing respiratory rate
c) cool, clammy skin, and pale mucous membranes
d) altered mental status and level of consciousness

Answer 16

a

a rising pulse rate and decreasing blood pressure are often the first indications of inadequate blood volume.

Question 17

a nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. which of the following factors should the nurse include in the teaching? (select all that apply.)

a) precipitous delivery
b) obesity
c) inversion of the uterus
d) oligohydramnios
e) retained placental fragments

Answer 17

a, c, e
rapid, precipitous delivery; inversion of the uterus; and retained placental fragments are risk factors for postpartum hemorrhage.

Question 18

a nurse on a postpartum unit is assessing a client who is being admitted with a suspected deep-vein thrombosis. which of the following clinical findings should the nurse expect? (select all that apply.)

a) calf tenderness to palpation
b) mottling of the affected extremity
c) elevated temperature
d) area of warmth
e) report of nausea

Answer 18

a, c, d
a client report of calf tenderness to palpation, elevated temperature, and an area of warmth over the thrombus are expected findings in a client who has a DVT.

Question 19

a nurse is planning care for a client who is postpartum and has thrombophlebitis. which of the following nursing interventions should the nurse include in the plan of care?

a) apply cold compresses to the affected extremity.
b) massage the affected extremity.
c) allow the client to ambulate.
d) measure leg circumferences.

Answer 19

d

plan to measure the circumference of the leg to assess for changes in the client’s condition.

Question 20

a nurse is caring for a client who has disseminated intravascular coagulation. which of the following antepartum complications should the nurse understand is a risk factor for this condition?

a) preeclampsia
b) thrombophlebitis
c) placenta previa
d) hyperemesis gravidarum

Answer 20

a

DIC can occur secondary in a client who has preeclampsia.

Question 21

a nurse on the postpartum unit is caring for four clients. which of the following clients should the nurse recognize at the greatest risk for development of a postpartum infection?

a) a client who experienced a precipitous labor less than 3 hr in duration
b) a client who had premature rupture of membranes and prolonged labor
c) a client who delivered a large for gestational age infant
d) a client who had a boggy uterus that was not we–contracted

Answer 21

b
premature rupture of membranes with prolonged labor poses the greatest risk for developing a postpartum infection because the birth canal was open, allowing pathogens to enter.

Question 22

a nurse is teaching a client who is breastfeeding and has mastitis. which of the following responses should the nurse make?

a) “limit the amount of time the infant nurses on each breast.”
b) “nurse the infant only on the unaffected breast until resolved.”
c) “completely empty each breast at each feeding or use a pump.”
d) “wear a tight-fitting bra until lactation has ceased.”

Answer 22

c
instruct the client to completely each breast at each feeding to prevent milk stasis, which provides a medium for bacterial growth.

Question 23

a nurse is reviewing discharge teaching with a client who has a urinary tract infection. which of the following statements by the client indicates understanding of the teaching? (select all that apply.)

a) “i will perform perineal care and apply a perineal pad in a back-to-front direction.”
b) “i will drink grape juice to make my urine more acidic.”
c) “i will drink large amounts of fluids to flush the bacteria from my urinary tract.”
d) “i will go back to breastfeeding after i have finished taking the antibiotic.”
e) “i will take tylenol for any discomfort.”

Answer 23

c, e
increased fluid intake can help to flush bacteria from the urinary tract. acetaminophen is taken to reduce discomfort and pain associated with a urinary tract infection.

Question 24

a nurse is caring for a client who has mastitis. which of the following is the typical causative agent of mastitis?

a) stahpylococcus aureus
b) chlamydia trachomatis
c) klebsiella pneumonia
d) clostridium perfringens

Answer 24

a
staphylococcus aureus, escherichia coli, and and streptococcus are usually the infecting agents that enter the breast due to sore or cracked nipples, which results in mastitis.

Question 25

a nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. which of the following conditions should the nurse include in the teaching? (select all that apply.)

a) epidural anesthesia
b) urinary bladder catheterization
c) frequent pelvic examinations
d) history of UTIs
e) vaginal birth

Answer 25

a, b, c, d
epidural anesthesia, urinary bladder catheterization, a history of frequent pelvic examinations, and a history of UTIs are risk factors for developing UTIs.

Question 26

a nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. which of the following conditions are associated with these manifestations?

a) postpartum fatigue
b) postpartum psychosis
c) letting-go phase
d) postpartum blues

Answer 26

d

postpartum blues are characterized by tearfulness, insomnia, lack of appetite, and feeling let-down.

Question 27

a nurse is caring for a postpartum client who delivered their third infant 2 days ago. which of the following manifestations could indicate postpartum depression? (select all that apply).

a) fatigue
b) insomnia
c) euphoria
d) flat affect
e) delusions

Answer 27

a, b, d

fatigue, insomnia, and a flat affect are findings suggestive of postpartum depression.

Question 28

a nurse is assessing a client who has postpartum depression. the nurse should expect which of the following manifestations? (select all that apply).

a) paranoia that their infant will be harmed
b) concerns about lack of income to pay bills
c) anxiety about assuming a new role as a parent
d) rapid decline in estrogen and progesterone
e) feeling of inadequacy with the new role as a parent

Answer 28

b, c, d, e
feelings of financial inadequacy to provide for family, anxiety about assuming a new role as a parent, the rapid decline in estrogen and progesterone, and feeling of inadequacies with the new role as a mother are findings associated with postpartum depression.

Question 29

a nurse is caring for a client who has postpartum psychosis. which of the following actions is the nurse’s priority?

a) reinforce the need to take antipsychotics as prescribed.
b) ask the client if they have thoughts of harming themselves or their infant.
c) monitor the infant for indications of failure to thrive.
d) review the client’s medical record for a history of bipolar disorder.

Answer 29

b
identify that the greatest risk to the client and the infant is self-harm or harm directed toward the infant. therefore, the priority action to take is to directly ask the client if they have thoughts of self-harm, suicide, or harming the infant.

Question 30

the nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. the client complains to the nurse of feelings of faintness and dizziness. which nursing action is most appropriate?

1) raise the head of the client’s bed.
2) obtain hemoglobin and hematocrit levels.
3) instruct the client to request help when getting out of bed.
4) inform the nursery room nurse to avoid bringing the newborn to the client until the client’s symptoms have subsided.

Answer 30

3
orthostatic hypotension may be evident during the first 8 hours after birth. feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client’s safety. the nurse should advise the client to get help the first few times she gets out of bed.

Question 31

the postpartum nurse is providing instructions to a client after birth of a healthy newborn. which time frame should the nurse relay to the client regarding the return of bowel function?

1) 3 days postpartum
2) 7 days postpartum
3) on the day of birth
4) within 2 weeks postpartum

Answer 31

1
after birth, the nurse should auscultate the client’s abdomen in all 4 quadrants to determine the return of bowel sounds. normal bowel elimination usually returns 2 to 3 days postpartum. surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions.

Question 32

the nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. the client required an episiotomy and has several hemorrhoids. what is the priority nursing consideration for this client?

1) client pain level
2) inadequate urinary output
3) client perception of body changes
4) potential for imbalanced body fluid volume

Answer 32

1
the priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. most clients have some degree of discomfort during the immediate postpartum period. there are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

Question 33

the nurse is providing postpartum instructions to a client who will be breast-feeding their newborn. the nurse determines that the client understood the instructions if she makes which statements? select all that apply.

1) “i should wear a bra that provides support.”
2) “drinking alcohol can affect my milk supply.”
3) “the use of caffeine can decrease my milk supply.”
4) “i will start my estrogen birth control pills again as soon as i get home.”
5) “i know if my breasts get engorged, i will limit my breast-feeding and supplement the baby.”
6) “i plan on having bottled water available in the refrigerator so i can get additional fluids easily.”

Answer 33

1, 2, 3, 6
the postpartum client should wear a bra that is well fitted and supportive. common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and the use of caffeine, alcohol, or medications. breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance on increasing fluids. if engorgement occurs, the client should not limit breast-feeding but should breast-feed frequently. oral contraceptives containing estrogen are not recommended for breast-feeding mothers.

Question 34

the nurse is teaching a postpartum client about breast-feeding. which instruction should the nurse include?

1) the diet should include additional fluids.
2) prenatal vitamins should be discontinued.
3) soap should be used to cleanse the breasts.
4) birth control measures are unnecessary while breast-feeding.

Answer 34

1
the diet for a breast-feeding client should include additional fluids. prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. breast-feeding is not a method of contraception, so birth control measures should be resumed.

Question 35

the nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. after locating the fundus, the nurse notes that the uterus feels soft and boggy. which nursing intervention is appropriate?

1) elevate the client’s legs.
2) massage the fundus until it is firm.
3) ask the client to turn on her left side.
4) push on the uterus to assist in expressing clots.

Answer 35

2
if the uterus is not contracted firmly, the initial intervention is to massage until it is firm and to express clots that may have accumulated in the uterus. elevating the client’s legs and positioning the client on the side would not assist in managing uterine atony. pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

Question 36

the nurse is caring for four 1-day postpartum clients. which client assessment requires the need for follow-up?

1) the client with mild afterpains
2) the client with a pulse rate of 60 beats per minute
3) the client with colostrum discharge from both breasts
4) the client with lochia that is red and has a foul-smelling odor

Answer 36

4
lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. normal lochia has a fleshy odor or an odor similar to menstrual flow. foul-smelling or purulent lochia usually indicates infection, and these findings are not normal.

Question 37

when performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. the nurse examines the clots and notes that they are larger than 1 cm. which nursing action is most appropriate?

1) document the findings.
2) notify the obstetrician.
3) reassess the client in 2 hours.
4) encourage increased oral intake of fluids.

Answer 37

2
normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. clots larger than 1 cm are considered abnormal. the cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. although the findings would be documented, the appropriate action is to notify the OB. reassessing the client in 2 hours would delay necessary treatment. increasing oral intake of fluids would not be a helpful action in this situation.

Question 38

the nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. how should the nurse respond to this finding initially?

1) document the finding.
2) encourage the client to ambulate.
3) encourage the client to increase fluid intake.
4) contact the obstetrician and inform him or her of this finding.

Answer 38

4
lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. the following can be used as a guide to determine the amount of flow: scant=less than 2.5 cm on menstrual pad in 1 hour; light=less than 10 cm on menstrual pad in 1 hour; moderate=less than 15 cm on menstrual pad in 1 hour; heavy=saturated menstrual pad in 1 hour; and excessive=menstrual pad saturated in 15 minutes. if the client is experiencing excessive bleeding, the nurse should contact the OB in the event that postpartum hemorrhage is occurring. it may be appropriate to encourage increased fluid intake, but this is not the initial action. it is not appropriate to encourage ambulation at this time. documentation should occur once the client has been stabilized.

Question 39

the nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. which statement made by the client indicates a need for further instruction?

1) “i will begin abdominal exercises immediately.”
2) “i will notify my obstetrician if i develop a fever.”
3) “i will turn on my side and push up with my arms to get out of bed.”
4) “i will lift nothing heavier than my newborn baby for at least 2 weeks.”

Answer 39

1
a cesarean delivery requires an incision made through the abdominal wall and into the uterus. abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision.

Question 40

after a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. what should the nurse do to help the woman process the delivery?

1) encourage the mother to breast-feed soon after birth.
2) support the mother in her reaction to the newborn infant.
3) tell the mother that it is important to hold the newborn infant.
4) document a complete account of the mother’s reaction on the birth record.

Answer 40

2
precipitous labor is labor that lasts 3 hours or less. women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. to assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant.

Question 41

the nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. which sign, if noted, would be an early sign of excessive blood loss?

1) a temperature of 100.4 degrees F
2) an increase in the pulse rate from 88 to 102 beats per minute
3) a blood pressure change from 130/88 to 124/80 mm Hg
4) an increase in the respiratory rate from 18 to 22 breaths per minute

Answer 41

2
during the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. an increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. a slight increase in temperature is normal. the blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. the respiratory rate is slightly increased from normal.

Question 42

the nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. which instructions should be included on the list? select all that apply.

1) wear a supportive bra.
2) rest during the acute phase.
3) maintain a fluid intake of at least 3000 mL/day.
4) continue to breast-feed if the breasts are not too sore.
5) take the prescribed antibiotics until the soreness subsides.
6) avoid decompression of the breasts by breast-feeding or breast pump.

Answer 42

1, 2, 3, 4
mastitis is an inflammation of the lactating breast as a result of infection. client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day, and taking analgesics to relieve discomfort. antibiotics may be prescribed and are taken until the complete prescribed course is finished. they are not stopped when the soreness subsides. additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

Question 43

the nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. which client statement would indicate a need for further instruction?

1) “i should breast-feed every 2 to 3 hours.”
2) “i should change the breast pads frequently.”
3) “i should wash my hands well before breast-feeding.”
4) “i should wash my nipples daily with soap and water.”

Answer 43

4
mastitis is inflammation of the breast as a result of infection. it generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. the mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours.

Question 44

the postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. which sign should the nurse note if superficial venous thrombosis is present?

1) paleness of the calf area
2) coolness of the calf area
3) enlarged, hardened veins
4) palpable dorsalis pedis pulses

Answer 44

3
thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. it also may be possible to palpate the enlarged, hard vein. clients sometimes experience pain when they walk. palpable dorsalis pedis pulses is a normal finding.

Question 45

a client in a postpartum unit complains of sudden sharp chest pain and dyspnea. the nurse notes that the client is tachycardic and the respiratory rate is elevated. the nurse suspects pulmonary embolism. which should be the initial nursing action?

1) initiate an intravenous line.
2) assess the client’s blood pressure.
3) prepare to administer morphine sulfate.
4) administer oxygen, 8 to 10 L/minute, by face mask.

Answer 45

4
if pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. oxygen is used to decrease hypoxia. the client is also kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. an intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

Question 46

the nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. which should be the initial nursing action?

1) record the findings.
2) massage the fundus.
3) notify the obstetrician.
4) place the client in trendelenburg’s position.

Answer 46

3
if bleeding is excessive, the cause may be laceration of the cervix or birth canal. massaging the fundus if it is firm would not assist in controlling the bleeding. trendelenburg’s position should be avoided because it may interfere with cardiac and respiratory function. although the nurse would record the findings, the initial nursing action would be to notify the OB.

Question 47

the nurse is preparing to care for four assigned clients. which client is at most risk for hemorrhage?

1) a primiparous client who delivered 4 hours ago
2) a multiparous client who delivered 6 hours ago
3) a multiparous client who delivered a large baby after oxytocin induction
4) a primiparous client who delivered 6 hours ago and had epidural anesthesia

Answer 47

3
the causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. the multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do other clients.

Question 48

a postpartum client is diagnosed with cystitis. the nurse should plan for which priority action in the care of the client?

1) providing sitz baths
2) encouraging fluid intake
3) placing ice on the perineum
4) monitoring hemoglobin and hematocrit levels

Answer 48

2
cystitis is an infection of the bladder. the client should consume 3000 mL of fluids per day if not contraindicated. sitz baths and ice would be appropriate interventions for perineal discomfort. hemoglobin and hematocrit levels would be monitored with hemorrhage.

Question 49

the nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. which assessment finding would best indicate the presence of a hematoma?

1) changes in vital signs
2) signs of heavy bruising
3) complaints of intense pain
4) complaints of a tearing sensation

Answer 49

1
because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma.

Question 50

the nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. the nurse should include which specific action during the first 12 hours after delivery?

1) encourage ambulation hourly.
2) assess vital signs every 4 hours.
3) measure fundal height every 4 hours.
4) prepare an ice pack for application to the area.

Answer 50

4
a hematoma is a localized collection of blood in the tissues of the reproductive tissues after delivery. vulvar hematoma is the most common. application of ice reduces swelling caused by hematoma formation in the vulvar area.

Question 51

on assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. the nurse should take which initial action?

1) document the findings.
2) elevate the client’s legs.
3) massage the fundus until it is firm.
4) push on the uterus to assist in expressing clots.

Answer 51

3
if the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. elevating the client’s legs would not assist in managing uterine atony. documenting the findings is appropriate action but is not the initial action. pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

Question 52

methylergonovine is prescribed for a woman to treat postpartum hemorrhage. before administration of methylergonovine, what is the priority assessment?

1) uterine tone
2) blood pressure
3) amount of lochia
4) deep tendon reflexes

Answer 52

2
methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. methylergonovine causes continuous uterine contractions and may elevate the blood pressure. a priority assessment before the administration of the medication is to check the blood pressure. the obstetrician needs to be notified if hypertension is present.

Question 53

Rh immune globulin is prescribed for a client after delivery, and the nurse provides information to the client about the purpose of the medication. the nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?

1) having Rh-positive blood
2) developing a rubella infection
3) developing physiological jaundice
4) being affected by Rh incompatibility

Answer 53

4
Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. during pregnancy and at delivery, some of the fetus’s Rh-positive blood can enter the maternal circulation, causing the mother’s immune system to form antibodies against Rh-positive blood. administration of Rh immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.
Rh immune globulin is prescribed for a client after delivery, and the nurse provides information to the client about the purpose of the medication. the nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?
1) having Rh-positive blood
2) developing a rubella infection
3) developing physiological jaundice
4) being affected by Rh incompatibility

4

Question 54

methylergonovine is prescribed for a client with postpartum hemorrhage. before administering the medication, the nurse should contact the obstetrician who prescribed the medication if which condition is documented in the client’s medical history?

1) hypotension
2) hypothyroidism
3) diabetes mellitus
4) peripheral vascular disease

Answer 54

4
methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. these conditions are worsened by the vasoconstrictive effects of the ergot alkaloids