FINAL ch 13, 16, 21 Flashcards
A laboring patient has entered the second stage of labor. Which assessment finding is most consistent with this stage?
A. Cervical dilation at 4 cm with mild contractions
B. Contractions occurring every 2–3 minutes, lasting 60–90 seconds
C. Expulsion of the placenta
D. Close monitoring of maternal vital signs and newborn stability
B. Contractions occurring every 2–3 minutes, lasting 60–90 seconds
Rationale: The second stage of labor begins when the cervix is completely dilated and ends with the birth of the newborn. Contractions during this stage are typically strong, occurring every 2–3 minutes, and lasting 60–90 seconds.
Which intervention is most critical during the third stage of labor?
A. Encouraging the patient to push with each contraction
B. Providing ice packs to the perineal area for swelling
C. Monitoring for uterine atony and excessive bleeding
D. Assessing maternal vital signs every 15 minutes
C. Monitoring for uterine atony and excessive bleeding
Rationale: The third stage of labor involves the expulsion of the placenta. Monitoring for uterine atony and excessive bleeding is critical during this stage to prevent postpartum hemorrhage.
The nurse is caring for a postpartum patient in the fourth stage of labor. Which finding would require immediate intervention?
A. Uterine fundus firm and midline
B. Heavy vaginal bleeding with clots
C. Maternal vital signs stable
D. Newborn in skin-to-skin contact with the mother
B. Heavy vaginal bleeding with clots
Rationale: The fourth stage of labor is the restorative period when the mother’s body begins to stabilize. Heavy vaginal bleeding with clots is abnormal and may indicate postpartum hemorrhage, requiring immediate intervention.
A patient in active labor asks how long the first stage of labor will last. Which response by the nurse is most appropriate?
A. “The first stage typically lasts 5–6 hours for all women.”
B. “It ends when you begin pushing, and that should happen in about 2 hours.”
C. “This stage is the shortest, lasting 1–2 hours.”
D. “It depends on how quickly your cervix dilates, but it is generally the longest stage of labor.”
D. “It depends on how quickly your cervix dilates, but it is generally the longest stage of labor.”
Rationale: The first stage of labor is the longest and varies in duration, depending on factors such as whether the patient is a first-time mother (nulliparous) or has delivered before (multiparous). It begins with true contractions and ends with full cervical dilation.
During the first stage of labor, which primary factor contributes to the pain experienced by the laboring patient?
A. Distention of the cervix and lower uterine segment
B. Compression of the fetal head against the pelvis
C. Expulsion of the placenta
D. Pressure on the perineum during contractions
A. Distention of the cervix and lower uterine segment
Rationale: Pain during the first stage of labor primarily results from cervical and lower uterine segment dilation, as well as the stretching of these structures during uterine contractions.
A nurse is caring for a multiparous patient in the first stage of labor. Based on the average duration for this stage, what should the nurse anticipate?
A. The first stage will last no longer than 8 hours
B. The first stage may last up to 20 hours
C. The first stage may last up to 14 hours
D. The first stage will not exceed 10 hours
C. The first stage may last up to 14 hours
Rationale: For multiparous women, the first stage of labor can last up to 14 hours without being considered prolonged. For primigravidas, it may last up to 20 hours.
Which assessment finding indicates the end of the first stage of labor?
A. Cervical dilation at 10 cm
B. Complete effacement of the cervix
C. Fetal membranes have ruptured
D. Regular contractions lasting 60 seconds
A. Cervical dilation at 10 cm
Rationale: The first stage of labor ends when the cervix is fully dilated to 10 cm, allowing the fetal head to pass through.
A primigravida patient asks why her labor is taking longer than expected. What is the best response by the nurse?
A. “Labor always takes longer for first-time mothers.”
B. “You may need an intervention if your labor doesn’t progress soon.”
C. “The first stage can take up to 20 hours for first-time mothers, but this is normal.”
D. “The duration depends on the size of your baby’s head.”
C. “The first stage can take up to 20 hours for first-time mothers, but this is normal.”
Rationale: For first-time mothers (primigravidas), the first stage of labor can last up to 20 hours without being considered prolonged. This is due to the time it takes for the cervix to dilate fully.
During a vaginal examination, the nurse determines that a laboring patient’s cervix is dilated to 7 cm. Which phase of the first stage of labor is the patient experiencing?
A. Transition phase
B. Latent phase
C. Active phase
D. Expulsive phase
C. Active phase
Rationale: The active phase of the first stage of labor is characterized by cervical dilation from 4 to 10 cm. This phase involves more rapid cervical dilation compared to the latent phase.
Which cervical dilation measurement is most consistent with the latent phase of labor?
A. 1–6 cm
B. 6–10 cm
C. 7–8 cm
D. 0–2 cm
A. 1–6 cm
Rationale: The latent phase of labor begins with the onset of regular contractions and ends when rapid cervical dilation begins. Cervical dilation progresses slowly during this phase, reaching approximately 6 cm.
A nurse is assessing a laboring patient during the latent phase. Which contraction characteristics are expected during this phase?
A. Occur every 2–3 minutes, lasting 60–90 seconds, and are strong by palpation
B. Occur every 5–10 minutes, lasting 30–45 seconds, and are mild by palpation
C. Occur every 5–10 minutes, lasting 60–90 seconds, and are moderate by palpation
D. Occur every 2–3 minutes, lasting 30–45 seconds, and are strong by palpation
B. Occur every 5–10 minutes, lasting 30–45 seconds, and are mild by palpation
Rationale: In the latent phase, contractions are mild, occur every 5–10 minutes, and last 30–45 seconds. The intensity is mild enough that the uterine fundus can be indented during palpation at the peak of the contraction.
During the latent phase of labor, which behavior is most commonly observed in the laboring woman?
A. Focused and intent on pushing
B. Restless and unable to communicate
C. Talkative and perceiving contractions as menstrual cramps
D. Silent and breathing deeply through contractions
C. Talkative and perceiving contractions as menstrual cramps
Rationale: Women in the latent phase are often talkative and may describe contractions as similar to menstrual cramps. This phase is characterized by excitement and apprehension about the start of labor.
What factor could prolong the latent phase of labor?
A. Administering sedation to the laboring woman
B. Use of oxytocin for labor augmentation
C. Early rupture of membranes
D. Strong uterine contractions
A. Administering sedation to the laboring woman
Rationale: Sedation can prolong the latent phase of labor by slowing the progression of cervical dilation.
A nurse palpates the fundus during a contraction and notes that it can be easily indented with her fingers. How should the nurse document the contraction intensity?
A. Strong
B. Moderate
C. Mild
D. Absent
C. Mild
Rationale: During the latent phase of labor, mild contractions are common. These can be assessed by palpating the uterine fundus; if it can be easily indented at the peak of the contraction, the intensity is considered mild.
Which assessment finding is most consistent with a laboring woman in the active phase of labor?
A. Contractions occurring every 5–10 minutes, lasting 30–45 seconds, and mild by palpation
B. Cervical dilation of 4–6 cm with mild discomfort
C. Contractions every 2–5 minutes, lasting 45–60 seconds, and moderate to strong by palpation
D. Cervical dilation of 10 cm with an urge to push
C. Contractions every 2–5 minutes, lasting 45–60 seconds, and moderate to strong by palpation
Rationale: During the active phase, contractions increase in frequency (every 2–5 minutes), duration (45–60 seconds), and intensity (moderate to strong). Cervical dilation occurs more rapidly compared to the latent phase.
What is the expected rate of cervical dilation during the active phase of labor?
A. 0.5 cm per hour
B. 1.0 cm per hour
C. 1.2 to 1.5 cm per hour
D. 2.0 to 2.5 cm per hour
C. 1.2 to 1.5 cm per hour
Rationale: Cervical dilation during the active phase of labor progresses predictably at a rate of approximately 1.2 to 1.5 cm per hour.
A laboring patient in the active phase begins to limit interactions with those in the room and appears focused on her contractions. What is the most appropriate nursing intervention?
A. Encourage her to engage with visitors to distract from the pain
B. Offer support by guiding her through relaxation and breathing techniques
C. Increase her activity level to promote faster cervical dilation
D. Administer sedatives to help her rest during labor
B. Offer support by guiding her through relaxation and breathing techniques
Rationale: During the active phase, women often become more inwardly focused to cope with the intensity of contractions. Supporting her with relaxation and breathing techniques helps her manage discomfort effectively.
Which physiological change is a hallmark of the active phase of labor?
A. Rapid and predictable cervical dilation
B. Complete effacement of the cervix
C. Rupture of the membranes
D. Transition of the fetus into the birth canal
A. Rapid and predictable cervical dilation
Rationale: The active phase of labor is characterized by a significant increase in the rate of cervical dilation, progressing rapidly and predictably until complete dilation at 10 cm.
A patient in active labor reports intense discomfort during contractions. The nurse palpates the uterine fundus and finds it difficult to indent at the peak of a contraction. How should the nurse document the contraction intensity?
A. Mild
B. Moderate
C. Strong
D. Absent
C. Strong
Rationale: Contractions during the active phase are typically moderate to strong in intensity. A fundus that is difficult to indent indicates strong contractions.
Which behavioral change is commonly observed in a woman during the active phase of labor?
A. Use of relaxation and paced breathing techniques
B. Increased interaction with her support team
C. Excitement and talkativeness
D. Urge to push with each contraction
A. Use of relaxation and paced breathing techniques
Rationale: Women in the active phase of labor often focus on coping with the increasing discomfort of contractions. If they have attended childbirth education classes, they typically employ relaxation and paced breathing techniques to manage their labor.
What physiological change signals the beginning of the second stage of labor?
A. Complete effacement of the cervix
B. Complete cervical dilation to 10 cm
C. Rupture of membranes
D. Fetal engagement in the pelvis
B. Complete cervical dilation to 10 cm
Rationale: The second stage of labor begins when the cervix is fully dilated to 10 cm and effacement is complete, marking the transition from cervical preparation to fetal descent through the birth canal.
A laboring patient in the second stage experiences an overwhelming urge to push. What causes this sensation?
A. Release of oxytocin during contractions
B. Pressure from the fetus on the pelvic floor and stretch receptors in the vaginal walls
C. Increased strength and duration of uterine contractions
D. Hormonal changes due to the expulsion of the placenta
B. Pressure from the fetus on the pelvic floor and stretch receptors in the vaginal walls
Rationale: The urge to push is caused by the fetus applying direct pressure to the pelvic floor, stimulating stretch receptors in the vaginal walls, rectum, and perineum, and leading to increased abdominal pressure.
Which contraction characteristics are expected during the second stage of labor?
A. Every 5–10 minutes, lasting 30–45 seconds, and mild by palpation
B. Every 2–3 minutes, lasting 60–90 seconds, and strong by palpation
C. Every 2–3 minutes, lasting 30–45 seconds, and moderate by palpation
D. Every 5–10 minutes, lasting 60–90 seconds, and strong by palpation
B. Every 2–3 minutes, lasting 60–90 seconds, and strong by palpation
Rationale: During the second stage, contractions occur every 2–3 minutes, last 60–90 seconds, and are strong by palpation to aid in the expulsion of the fetus through the birth canal.
Which maternal factors can prolong the second stage of labor?
A. Parity and presence of Braxton Hicks contractions
B. Maternal age and previous cesarean delivery
C. Uterine rupture and active hemorrhage
D. Maternal BMI, fetal station, and use of epidural analgesia
D. Maternal BMI, fetal station, and use of epidural analgesia
Rationale: Factors such as maternal BMI, delayed pushing, use of epidural analgesia, fetal station at complete dilation, and fetal positioning (e.g., occiput posterior) can prolong the second stage of labor.
Which complication is associated with a prolonged second stage of labor?
A. Umbilical cord prolapse
B. Preeclampsia
C. Third- and fourth-degree perineal lacerations
D. Amniotic fluid embolism
C. Third- and fourth-degree perineal lacerations
Rationale: Prolonged second stage of labor increases the risk of maternal complications such as perineal lacerations, puerperal infections, and postpartum hemorrhage.
During the second stage of labor, a patient expresses feelings of control and focus while pushing. What is the most appropriate nursing action?
A. Encourage the patient to continue pushing during contractions
B. Prepare the patient for an emergency cesarean section
C. Administer a sedative to help the patient rest
D. Interrupt pushing to assess for uterine rupture
A. Encourage the patient to continue pushing during contractions
Rationale: During the second stage, the mother often feels in control and focused on pushing. The nurse should provide encouragement and guidance to support effective pushing efforts during contractions.
What is the primary function of the cardinal movements of labor during the second stage?
A. Reduce maternal pain during contractions
B. Encourage uterine relaxation between contractions
C. Prevent fetal distress during labor
D. Facilitate the fetus’s movement through the birth canal
D. Facilitate the fetus’s movement through the birth canal
Rationale: The cardinal movements of labor are a series of positional changes that the fetus undergoes to navigate the birth canal and facilitate delivery.
A nurse is assessing a laboring patient in the second stage. Which finding indicates that the fetus is descending through the birth canal?
A. Fetal heart rate variability
B. Rupture of membranes
C. Contractions spaced further apart
D. Pressure felt in the pelvic floor and rectum
D. Pressure felt in the pelvic floor and rectum
Rationale: Pressure in the pelvic floor and rectum indicates fetal descent through the birth canal, stimulating stretch receptors and contributing to the maternal urge to push.
What physiological change is associated with the crowning of the fetal head during labor?
A. The fetal head becomes apparent at the vaginal opening and disappears between contractions.
B. The top of the fetal head remains visible between contractions.
C. The fetal head rotates internally during contractions.
D. The fetal presenting part exerts pressure on the rectum.
B. The top of the fetal head remains visible between contractions.
Rationale: Crowning occurs when the top of the fetal head no longer regresses between contractions and remains visible at the vaginal opening.
Which assessment finding is most consistent with the active pushing phase of labor?
A. Mild contractions occurring every 5–10 minutes
B. Full cervical dilation with a lack of bloody show
C. Rectal pressure and an overwhelming urge to push
D. Complete delivery of the placenta
C. Rectal pressure and an overwhelming urge to push
Rationale: During active pushing, the laboring mother feels rectal pressure caused by the fetal presenting part and experiences a physiological urge to push.
How does an epidural affect the active pushing phase of labor?
A. It dulls the sensation to push.
B. It intensifies the urge to push.
C. It shortens the duration of labor.
D. It eliminates bloody show.
A. It dulls the sensation to push.
Rationale: An epidural can dull the physiological urge to push, making the pushing phase less intense for the laboring mother.
What is a normal duration for the second stage of labor in a multiparous woman?
A. Up to 1 hour
B. Up to 2 hours
C. Up to 3 hours
D. Up to 4 hours
B. Up to 2 hours
Rationale: In multiparous women, the second stage of labor typically lasts up to 2 hours. In first labors, it may last up to 3 hours.
Which finding is a key indicator of progression during the second stage of labor?
A. Perineum bulging and increased bloody show
B. Uterine relaxation between contractions
C. Absence of fetal head at the vaginal opening
D. Contractions occurring every 5–10 minutes
A. Perineum bulging and increased bloody show
Rationale: The bulging of the perineum and an increase in bloody show indicate that the fetus is descending and labor is progressing during the second stage.
A nurse observes that the fetal head becomes visible at the vaginal opening but disappears between contractions. How should this stage of labor be documented?
A. Crowning
B. Early second stage
C. Late second stage
D. Fetal head engagement
C. Late second stage
Rationale: In the late second stage of labor, the fetal head becomes visible but may still regress between contractions until crowning occurs.
Which statement reflects current evidence about labor progression during the second stage?
A. The second stage progresses more rapidly than previously thought.
B. Labor progresses slower than previously thought, requiring more time for vaginal delivery.
C. Women with epidurals progress faster than those without epidurals.
D. Crowning is an indicator to initiate surgical birth.
B. Labor progresses slower than previously thought, requiring more time for vaginal delivery.
Rationale: Current evidence shows that labor progresses more slowly than previously believed, and many women may need additional time to achieve vaginal delivery without moving to surgical interventions.
What is the primary advantage of spontaneous pushing during the second stage of labor?
A. It reduces the total duration of the second stage.
B. It eliminates the need for maternal energy expenditure.
C. It prevents fetal descent.
D. It minimizes the risk of pelvic floor damage.
D. It minimizes the risk of pelvic floor damage.
Rationale: Spontaneous pushing reduces pelvic floor damage by avoiding the prolonged Valsalva maneuver, which is associated with more strain and injury.
Which is a significant drawback of directed pushing during labor?
A. Decreases maternal pain perception
B. Prolongs the overall labor process
C. Reduces fetal oxygenation and causes hemodynamic changes
D. Eliminates maternal participation
C. Reduces fetal oxygenation and causes hemodynamic changes
Rationale: Directed pushing, especially prolonged Valsalva bearing-down, can lead to hemodynamic changes in the mother and interfere with fetal oxygen exchange.
What is the World Health Organization’s (WHO) recommendation for managing the second stage of labor?
A. Encouraging women to follow their spontaneous urge to push
B. Immediate and directed pushing efforts after complete cervical dilation
C. Continuous monitoring and direction by the healthcare provider
D. Delaying pushing until the fetus crowns
A. Encouraging women to follow their spontaneous urge to push
Rationale: The WHO recommends encouraging women to follow their own urge to push rather than using directed pushing.
Which maternal behavior is consistent with a physiologic, woman-directed approach to pushing?
A. Using open-glottis pushing with grunting and vocalization
B. Holding their breath to the count of 10 during contractions
C. Pushing at fixed intervals based on caregiver instructions
D. Maintaining one position throughout labor
A. Using open-glottis pushing with grunting and vocalization
Rationale: A physiologic, woman-directed approach involves open-glottis pushing, allowing the mother to bear down naturally with involuntary efforts.
What is a primary benefit of delaying maternal pushing until the urge to bear down is felt?
A. Shortens the total time of labor
B. Increases the rate of cervical dilation
C. Prevents the need for epidural analgesia
D. Reduces maternal fatigue and improves fetal oxygenation
D. Reduces maternal fatigue and improves fetal oxygenation
Rationale: Delaying pushing conserves maternal energy and allows for better oxygenation of the fetus, optimizing outcomes for both mother and baby.
Which technique is associated with a physiologic approach to laboring down?
A. Coached Valsalva pushing immediately after complete cervical dilation
B. Passive fetal descent without maternal pushing
C. Using sustained breath-holding during contractions
D. Applying external fundal pressure to speed delivery
B. Passive fetal descent without maternal pushing
Rationale: Laboring down involves allowing passive fetal descent with minimal or no maternal pushing, particularly in women with epidurals.
Which of the following is a potential negative consequence of prolonged directed pushing?
A. Decreased maternal pain perception
B. Improved fetal oxygen exchange
C. Increased pelvic floor damage
D. Shortened second stage of labor
C. Increased pelvic floor damage
Rationale: Prolonged directed pushing increases the risk of pelvic floor damage and adverse maternal outcomes.
Which method best supports maternal energy conservation and optimal second-stage outcomes?
A. Encouraging laboring down
B. Immediate directed pushing after complete dilation
C. Using continuous maternal breath-holding
D. Limiting maternal positions to supine
A. Encouraging laboring down
Rationale: Laboring down allows for passive fetal descent, conserving maternal energy and improving overall outcomes.
Which technique is an example of evidence-based second-stage labor management?
A. Instructing the mother to push for 10 seconds with each contraction
B. Encouraging the mother to use her own pushing techniques
C. Administering fundal pressure to assist fetal descent
D. Restricting movement to one position during labor
B. Encouraging the mother to use her own pushing techniques
Rationale: Evidence-based management supports the mother’s spontaneous patterns and techniques of pushing in response to her sensations.
What physiological change occurs during open-glottis pushing?
A. Increased intrathoracic pressure from breath-holding
B. Decreased strength and duration of contractions
C. Expiratory grunting with involuntary bearing down
D. Improved maternal blood pressure regulation
C. Expiratory grunting with involuntary bearing down
Rationale: Open-glottis pushing involves natural expiratory grunting and involuntary bearing down, which aligns with the body’s physiological processes.
Which factor contributes to the decision to delay maternal pushing?
A. A belief that delayed pushing increases cesarean rates
B. The need for constant caregiver monitoring
C. Reduced uterine contractions during the delay
D. Evidence suggesting improved maternal energy and fetal oxygenation
D. Evidence suggesting improved maternal energy and fetal oxygenation
Rationale: Delaying pushing optimizes maternal energy and enhances fetal oxygenation without increasing adverse outcomes.
Which maternal behavior indicates effective second-stage labor management?
A. Pushing at caregiver-directed intervals
B. Spontaneous variations in strength and duration of pushing
C. Avoiding vocalization during contractions
D. Maintaining a supine position throughout labor
B. Spontaneous variations in strength and duration of pushing
Rationale: Effective second-stage management involves the mother using her own natural patterns, including variations in strength and duration of pushing.
What should the nurse prioritize in evidence-based care during the second stage of labor?
A. Directing the mother to hold her breath during contractions
B. Supporting the mother’s spontaneous urge and position changes
C. Encouraging immediate epidural administration
D. Applying manual fundal pressure to speed labor
B. Supporting the mother’s spontaneous urge and position changes
Rationale: Evidence-based care during the second stage prioritizes supporting the mother’s natural instincts and encouraging position changes to enhance comfort and labor progress.
Which nursing intervention is the highest priority during the third stage of labor?
A. Monitoring maternal vital signs every 15 minutes
B. Assessing for signs of placental separation
C. Promoting immediate skin-to-skin contact between the newborn and mother
D. Administering a uterotonic agent as ordered
D. Administering a uterotonic agent as ordered
Rationale: Administering a uterotonic agent is critical to preventing postpartum hemorrhage, the leading cause of maternal mortality during the third stage of labor.
What indicates that placental separation has occurred?
A. A sudden gush of blood and lengthening of the umbilical cord
B. The uterus becomes soft and non-palpable
C. The mother feels the urge to push again
D. Fetal heart tones are audible on the Doppler
A. A sudden gush of blood and lengthening of the umbilical cord
Rationale: Placental separation is typically signaled by a gush of blood, lengthening of the umbilical cord, and changes in the uterine shape.
What is the primary benefit of skin-to-skin contact between the mother and newborn during the third stage of labor?
A. Decreases maternal blood loss
B. Accelerates placental separation
C. Prevents uterine inversion
D. Facilitates the newborn’s transition to extrauterine life
D. Facilitates the newborn’s transition to extrauterine life
Rationale: Skin-to-skin contact promotes thermoregulation, bonding, and adaptation of the newborn to extrauterine life.
What is a key component of active management of the third stage of labor?
A. Allowing the placenta to deliver naturally without intervention
B. Administering a uterotonic agent and performing controlled cord traction
C. Massaging the uterus before placental expulsion
D. Avoiding fundal massage to reduce maternal discomfort
B. Administering a uterotonic agent and performing controlled cord traction
Rationale: Active management involves administering a uterotonic, controlled cord traction, and uterine fundal massage after placental expulsion to prevent postpartum hemorrhage.
Which complication is most commonly associated with the third stage of labor?
A. Uterine rupture
B. Shoulder dystocia
C. Amniotic fluid embolism
D. Postpartum hemorrhage
D. Postpartum hemorrhage
Rationale: Postpartum hemorrhage is the most common complication during the third stage of labor and can be life-threatening without prompt intervention.
Which of the following statements about expectant management of the third stage of labor is correct?
A. It involves immediate administration of a uterotonic agent.
B. The placenta is delivered naturally without controlled cord traction.
C. Fundal massage is performed continuously until the placenta delivers.
D. It is more effective than active management in preventing hemorrhage.
B. The placenta is delivered naturally without controlled cord traction.
Rationale: Expectant management allows the placenta to deliver naturally without interventions such as controlled cord traction or uterotonic administration.
What is the nurse’s priority action if the uterus fails to contract after placental expulsion?
A. Reassess the placenta for completeness
B. Notify the provider and prepare for surgical intervention
C. Perform vigorous uterine fundal massage
D. Administer a second dose of a uterotonic agent as prescribed
C. Perform vigorous uterine fundal massage
Rationale: Uterine fundal massage stimulates contraction of the uterus and is a critical initial intervention to control bleeding and prevent uterine atony.
Which clinical finding indicates that the placenta is ready to deliver?
A. The uterus becomes soft and non-palpable.
B. The umbilical cord shortens and retracts.
C. The uterus changes its shape to globular.
D. The maternal blood pressure drops suddenly.
C. The uterus changes its shape to globular.
Rationale: A globular-shaped uterus, along with upward rising of the uterus, cord lengthening, and a sudden trickle of blood, are all signs that the placenta has separated from the uterine wall and is ready to deliver.
What is the distinguishing feature of a placenta delivered by the Schultz mechanism?
A. The placenta delivers spontaneously without uterine contractions.
B. The red, raw maternal side presents first.
C. The umbilical cord detaches during delivery.
D. The shiny, gray fetal side presents first.
D. The shiny, gray fetal side presents first.
Rationale: In the Schultz mechanism, the fetal side (shiny gray) of the placenta delivers first, while the Duncan mechanism involves the maternal side (red raw) delivering first.
Which of the following interventions is the priority during placental delivery?
A. Monitoring for signs of incomplete placental separation.
B. Applying firm downward pressure on the fundus to expedite expulsion.
C. Pulling gently on the umbilical cord immediately after birth of the fetus.
D. Administering oxytocin before the placenta is delivered.
A. Monitoring for signs of incomplete placental separation.
Rationale: It is critical to monitor for signs of incomplete placental separation to prevent complications such as hemorrhage or retained placenta.
The maternal side of the placenta presenting first during delivery is referred to as:
A. Shiny Schultz mechanism.
B. Placental inversion.
C. Secondary placental expulsion.
D. Duncan mechanism.
D. Duncan mechanism.
Rationale: The maternal side (red and raw) of the placenta presenting first is termed the Duncan mechanism, while the fetal side (shiny and gray) is the Schultz mechanism.
What causes the placenta to separate from the uterine wall after birth of the infant?
A. Continuous uterine contractions and retraction.
B. A sudden decrease in maternal blood pressure.
C. Mechanical traction on the umbilical cord.
D. Hormonal changes reducing uterine blood supply.
A. Continuous uterine contractions and retraction.
Rationale: After the infant is born, strong uterine contractions and retraction decrease the uterine size, pulling the placenta away from the uterine wall.
What is the primary purpose of uterine massage immediately after placental expulsion?
A. To relieve maternal pain and discomfort.
B. To promote uterine contraction and prevent hemorrhage.
C. To facilitate the birth of any remaining fetal tissue.
D. To promote the passage of urine.
B. To promote uterine contraction and prevent hemorrhage.
Rationale: Uterine massage is performed to help the uterus contract, which constricts blood vessels and reduces the risk of postpartum hemorrhage.
Which of the following is considered a normal blood loss for a vaginal birth?
A. 500 mL
B. 1,000 mL
C. 1,500 mL
D. 2,000 mL
A. 500 mL
Rationale: Normal blood loss during a vaginal birth is typically around 500 mL, with up to 1,000 mL considered normal for a cesarean birth.
What is the potential risk if any portion of the placenta remains attached to the uterine wall after expulsion?
A. Preterm labor.
B. Postpartum hemorrhage.
C. Uterine rupture.
D. Eclampsia.
B. Postpartum hemorrhage.
Rationale: Retained placental tissue can interfere with uterine contractions, leading to postpartum hemorrhage due to failure of the uterus to contract fully.
When is external traction typically used during placental expulsion?
A. Only when the placenta fails to separate.
B. After the first hour of the third stage of labor.
C. In the case of a cesarean delivery to assist with placental removal.
D. Immediately after the birth of the fetus regardless of placental separation.
A. Only when the placenta fails to separate.
Rationale: External traction is used only if the placenta fails to separate spontaneously, assisting with its expulsion in a timely manner.
What is considered severe blood loss after a vaginal birth?
A. 200 mL
B. 500 mL
C. 750 mL
D. 1,000 mL
D. 1,000 mL
Rationale: Severe blood loss is defined as greater than 1,000 mL following vaginal birth, which increases the risk of complications such as hypovolemic shock.
How long after the birth of the newborn should the placenta typically be expelled?
A. Within 1 to 5 minutes
B. Within 10 to 15 minutes
C. Within 2 to 30 minutes
D. Within 1 hour
C. Within 2 to 30 minutes
Rationale: The placenta is typically expelled within 2 to 30 minutes following birth, depending on whether external traction is used or the placenta delivers spontaneously.
What would be the most likely intervention if the placenta does not expel within the expected time frame?
A. Manual extraction by the healthcare provider.
B. Immediate administration of oxytocin.
C. External rotation of the placenta.
D. Allowing the placenta to remain for an additional hour.
A. Manual extraction by the healthcare provider.
Rationale: If the placenta does not expel within the normal time frame, manual extraction by the healthcare provider is necessary to prevent complications such as hemorrhage.
Which of the following actions should be taken if the uterus becomes boggy in the fourth stage of labor?
A. Administer an analgesic to the mother.
B. Perform manual extraction of the placenta.
C. Massage the fundus to encourage firm contraction.
D. Immediately perform a cesarean section.
C. Massage the fundus to encourage firm contraction.
Rationale: If the uterus becomes boggy (soft), the nurse should massage the fundus to encourage uterine contraction, which helps prevent postpartum hemorrhage.
During the fourth stage of labor, what is a common sign of uterine atony (boggy uterus)?
A. Excessive maternal thirst.
B. A firm and midline fundus.
C. A soft, non-contracted fundus.
D. Bright red lochia.
C. A soft, non-contracted fundus.
Rationale: A boggy uterus, which is soft and not well-contracted, is a sign of uterine atony, a risk factor for postpartum hemorrhage.
What should be the nurse’s primary focus during the fourth stage of labor?
A. To educate the mother about newborn care.
B. To monitor for complications such as hemorrhage, bladder distention, and venous thrombosis.
C. To begin prenatal care for the next pregnancy.
D. To encourage the mother to walk and move around immediately.
B. To monitor for complications such as hemorrhage, bladder distention, and venous thrombosis.
Rationale: The primary focus during the fourth stage is to monitor the mother closely for complications, including hemorrhage, bladder distention, and venous thrombosis.
What is the typical location of the fundus in the first hour after birth during the fourth stage of labor?
A. Below the symphysis pubis.
B. At the level of the umbilicus.
C. Midline between the umbilicus and the symphysis.
D. Above the umbilicus.
B. At the level of the umbilicus.
Rationale: In the first hour after birth, the fundus typically rises to the level of the umbilicus, and its position is monitored for signs of uterine atony.
Which of the following is a common maternal symptom during the fourth stage of labor due to uterine contraction?
A. Severe headache.
B. Chest pain.
C. Cramp-like discomfort.
D. Abdominal bloating.
C. Cramp-like discomfort.
Rationale: Cramp-like discomfort is common during the fourth stage of labor as the uterus contracts to its pre-pregnancy size.
What is the typical characteristic of lochia in the fourth stage of labor?
A. Clear and watery with no clots.
B. Red in color, mixed with small clots, and of moderate flow.
C. Yellow with a strong odor.
D. Greenish with heavy flow and large clots.
B. Red in color, mixed with small clots, and of moderate flow.
Rationale: Lochia during the fourth stage is typically red, mixed with small clots, and has moderate flow as the body expels the remaining blood and tissue from the uterus.
What vital signs should be monitored most frequently during the fourth stage of labor, especially within the first hour?
A. Blood pressure and temperature.
B. Heart rate and respiratory rate.
C. Blood pressure, heart rate, and temperature.
D. Blood pressure, heart rate, and fundus status.
D. Blood pressure, heart rate, and fundus status.
Rationale: Vital signs, including blood pressure, heart rate, and fundus status, should be monitored every 15 minutes during the first hour after birth to assess for complications.
Why might a woman feel hungry and thirsty during the fourth stage of labor?
A. Due to dehydration from labor.
B. Because of the effect of epidural anesthesia.
C. Due to the physical exertion of labor and delivery.
D. Due to an increased metabolic rate.
C. Due to the physical exertion of labor and delivery.
Rationale: The woman may feel hungry and thirsty after the physical exertion of labor and delivery, as the body requires energy to recover and stabilize after birth.
Which of the following hormonal changes is primarily responsible for the onset of labor?
A. Decrease in estrogen levels.
B. Decrease in progesterone levels.
C. Increase in progesterone levels.
D. Increase in testosterone levels.
B. Decrease in progesterone levels.
Rationale: The onset of labor is associated with a decrease in progesterone levels and an increase in estrogen and prostaglandins, which stimulate uterine contractions.
The most reliable sign that a woman is in active labor is:
A. Increased maternal anxiety.
B. Regular uterine contractions.
C. Complete effacement of the cervix.
D. Significant cervical change.
D. Significant cervical change.
Rationale: The most reliable sign of active labor is significant cervical change, which indicates that labor is progressing toward full dilation.
During the second stage of labor, what is the primary goal for the mother?
A. To focus on relaxation techniques.
B. To begin the process of pushing to deliver the baby.
C. To rest and conserve energy.
D. To monitor for signs of infection.
B. To begin the process of pushing to deliver the baby.
Rationale: The second stage of labor focuses on pushing and moving the fetus through the birth canal until the baby is born.
What is the primary focus during the third stage of labor?
A. Expulsion of the placenta.
B. Maternal recovery and rest.
C. Monitoring fetal heart tones.
D. Initiation of breastfeeding.
A. Expulsion of the placenta.
Rationale: The third stage of labor focuses on the expulsion of the placenta, ensuring it is fully delivered and the uterus contracts properly to minimize bleeding.
In the fourth stage of labor, which of the following is the priority nursing action for the mother during the first 1-4 hours postpartum?
A. Encourage bonding with the newborn.
B. Assess for signs of infection.
C. Begin education on newborn care.
D. Monitor for postpartum hemorrhage.
D. Monitor for postpartum hemorrhage.
Rationale: The priority action during the fourth stage is to monitor for postpartum hemorrhage, ensuring the uterus remains firm and contractions are effective in reducing bleeding.
Which stage of labor is characterized by the cervix dilating from full dilation to the birth of the infant?
A. First stage.
B. Second stage.
C. Third stage.
D. Fourth stage.
B. Second stage.
Rationale: The second stage of labor begins at full dilation and ends with the birth of the infant. This stage involves pushing and the descent of the fetus through the birth canal.
Which of the following Bishop scores indicates the highest likelihood of achieving a successful vaginal birth without the need for cervical ripening methods?
A. 3
B. 5
C. 7
D. 8
D. 8
Rationale: A Bishop score of over 8 indicates a high likelihood of a successful vaginal birth without the need for cervical ripening methods.
When a Bishop score is less than 6, what is typically indicated for the woman prior to labor induction?
A. Administration of a uterotonic agent.
B. Immediate cesarean delivery.
C. Use of cervical ripening methods.
D. Continuous fetal heart rate monitoring
C. Use of cervical ripening methods.
Rationale: A Bishop score less than 6 generally indicates the need for cervical ripening methods before induction of labor to improve the chances of a successful vaginal birth.
Which of the following components is NOT part of medical induction of labor?
A. Cervical ripening.
B. Induction of contractions.
C. Pelvic rest.
D. Evaluation of cervical readiness (Bishop score).
C. Pelvic rest.
Rationale: Pelvic rest is not a component of medical induction of labor. The two primary components are cervical ripening and induction of contractions, with cervical readiness evaluated through a Bishop score.
A 36-week pregnant patient is being assessed for induction of labor. Her Bishop score reveals the following:
Dilation: 2 cm, Effacement: 50%, Station: -2, Cervical Consistency: Medium, Position of Cervix: Midposition. What is her total Bishop score?
A. 3
B. 5
C. 7
D. 9
B. 5
Rationale: The patient’s Bishop score is calculated as follows: - Dilation (1–2 cm): 1 point - Effacement (40–50%): 1 point - Station (-2): 1 point - Cervical consistency (Medium): 1 point - Position of cervix (Midposition): 1 point Total = 5 points.
A Bishop score of less than 6 indicates which of the following?
A. Cervix is favorable for induction
B. Cervix is unfavorable for induction
C. The patient is in active labor
D. Immediate delivery is necessary
B. Cervix is unfavorable for induction
Rationale: A Bishop score less than 6 indicates an unfavorable cervix, suggesting that cervical ripening interventions may be necessary before induction of labor.
Which component of the Bishop scoring system assesses the location of the presenting part in relation to the ischial spines?
A. Effacement
B. Dilation
C. Cervical Consistency
D. Station
D. Station
Rationale: Station refers to the position of the presenting part of the fetus (e.g., head) relative to the ischial spines of the pelvis. It ranges from -3 (high in the pelvis) to +2 (near delivery).
A Bishop score of 8 or higher suggests which of the following? (SATA)
A. Increased likelihood of successful induction
B. Cervix is ripened
C. A Cesarean section is required
D. Patient is ready for labor induction
A. Increased likelihood of successful induction
B. Cervix is ripened
D. Patient is ready for labor induction
Rationale: A score of 8 or higher indicates the cervix is favorable for induction, with a high chance of a successful vaginal delivery.
A patient at 40 weeks of gestation has a Bishop score of 4. What intervention is most appropriate before initiating labor induction?
A. Administering oxytocin
B. Performing an amniotomy
C. Administering cervical ripening agents
D. Encouraging ambulation
C. Administering cervical ripening agents
Rationale: A Bishop score of 4 indicates an unfavorable cervix. Cervical ripening agents, such as prostaglandins, are typically used to soften and prepare the cervix for induction.
Which station measurement is assigned 2 points on the Bishop scoring system?
A. -3
B. -1
C. 0
D. +1
D. +1
Rationale: A station of +1 or +2 is assigned 2 points on the Bishop scoring system, indicating that the presenting part is low in the pelvis.
A patient is evaluated with the following cervical findings:
Dilation: 4 cm, Effacement: 80%, Station: +1, Cervical Consistency: Soft, Position of Cervix: Anterior. What is her Bishop score?
A. 6
B. 9
C. 11
D. 12
C. 11
Rationale: The patient’s Bishop score is calculated as follows: - Dilation (3–4 cm): 2 points - Effacement (80%): 3 points - Station (+1): 2 points - Cervical consistency (Soft): 2 points - Position of cervix (Anterior): 2 points Total = 11 points.
Which of the following findings would result in the lowest possible Bishop score?
A. Dilation: Closed, Effacement: 0–30%, Station: -3, Cervical Consistency: Firm, Position of Cervix: Posterior
B. Dilation: 1–2 cm, Effacement: 60–70%, Station: 0, Cervical Consistency: Medium, Position of Cervix: Midposition
C. Dilation: 3–4 cm, Effacement: 40–50%, Station: -1, Cervical Consistency: Soft, Position of Cervix: Anterior
D. Dilation: 5–6 cm, Effacement: 80%, Station: +2, Cervical Consistency: Very Soft, Position of Cervix: Anterior
A. Dilation: Closed, Effacement: 0–30%, Station: -3, Cervical Consistency: Firm, Position of Cervix: Posterior
Rationale: These findings (closed dilation, 0–30% effacement, -3 station, firm cervix, and posterior position) result in the lowest possible Bishop score of 0.
Cervical consistency changes during labor. Which consistency scores the highest on the Bishop scoring system?
A. Firm
B. Medium
C. Soft
D. Very soft
D. Very soft
Rationale: A “Very soft” cervix is assigned the highest score (3 points) for cervical consistency in the Bishop scoring system.
A Bishop score includes cervical dilation as a parameter. What score is given for a dilation of 5 cm?
A. 0
B. 1
C. 2
D. 3
D. 3
Rationale: A dilation of 5–6 cm scores 3 points in the Bishop scoring system.
A nulliparous patient is evaluated for labor induction. What is the minimum Bishop score required to indicate a favorable cervix?
A. 3
B. 5
C. 6
D. 8
C. 6
Rationale: A Bishop score of at least 6 is generally considered favorable for labor induction in nulliparous patients.
A Bishop score includes the position of the cervix. What score is assigned to an anterior cervix?
A. 0
B. 1
C. 2
D. 3
C. 2
Rationale: An anterior cervix scores 2 points in the Bishop scoring system.
Which cervical finding correlates with the maximum possible Bishop score for effacement?
A. 0–30%
B. 40–50%
C. 60–70%
D. 80%
D. 80%
Rationale: An effacement of 80% scores the maximum of 3 points for this parameter in the Bishop scoring system.
A patient is 39 weeks pregnant with a Bishop score of 9. What does this suggest about labor induction?
A. Induction is unlikely to succeed
B. The cervix is ripened and favorable for induction
C. A Cesarean section is necessary
D. Cervical ripening agents are required
B. The cervix is ripened and favorable for induction
Rationale: A score of 9 indicates a highly favorable cervix, with a high likelihood of successful labor induction.
Which components are included in the Bishop scoring system? (SATA)
A. Cervical dilation
B. Fetal heart rate
C. Effacement
D. Station
E. Position of cervix
A. Cervical dilation
C. Effacement
D. Station
E. Position of cervix
Rationale: The Bishop scoring system evaluates cervical dilation, effacement, station, cervical consistency, and position of the cervix to assess readiness for labor induction. Fetal heart rate is not included.
Which cervical characteristics indicate that a cervix is ripe for labor induction?
A. Long, firm, and posterior.
B. Closed, soft, and posterior.
C. Shortened, softened, and anterior.
D. Long, closed, and anterior.
C. Shortened, softened, and anterior.
Rationale: A ripe cervix is described as shortened, softened, and anterior. These changes increase the likelihood of successful labor induction and vaginal birth.
What does a Bishop score of less than 6 indicate?
A. The need for cervical ripening before induction of labor.
B. The need for immediate delivery via cesarean section.
C. A high likelihood of spontaneous labor.
D. The absence of cervical effacement.
A. The need for cervical ripening before induction of labor.
Rationale: A Bishop score of less than 6 suggests the cervix is unfavorable and indicates the need for cervical ripening before labor induction to increase the chances of a successful vaginal delivery.
Which of the following best describes the purpose of cervical ripening prior to labor induction?
A. To initiate uterine contractions.
B. To allow for collagen breakdown, softening, and elasticity of the cervix.
C. To prevent premature labor.
D. To reduce the risk of postpartum hemorrhage.
B. To allow for collagen breakdown, softening, and elasticity of the cervix.
Rationale: Cervical ripening involves the breakdown of collagen, leading to cervical softening, elasticity, and distensibility, which are necessary for cervical dilation and effacement.
Which method is NOT typically used for cervical ripening?
A. Mechanical dilation using a Foley catheter.
B. Pharmacologic agents such as prostaglandins.
C. Continuous fetal monitoring.
D. Membrane sweeping.
C. Continuous fetal monitoring.
Rationale: Continuous fetal monitoring is used during labor but is not a method for cervical ripening. Mechanical and pharmacologic methods, as well as membrane sweeping, are commonly used for this purpose.
A nurse is assessing a patient with a Bishop score of 9. What conclusion can the nurse make based on this score?
A. Cervical ripening methods are required before induction.
B. The cervix is unfavorable for induction.
C. A successful vaginal birth is likely.
D. The patient is in active labor.
C. A successful vaginal birth is likely.
Rationale: A Bishop score of 8 or higher indicates a ripe cervix, suggesting a high likelihood of a successful vaginal birth without additional cervical ripening methods.
What is the primary goal of mechanical cervical ripening methods?
A. To reduce uterine contractions.
B. To increase the levels of progesterone.
C. To promote the descent of the fetus into the pelvis.
D. To apply continuous pressure to the cervix to stimulate effacement and dilation.
D. To apply continuous pressure to the cervix to stimulate effacement and dilation.
Rationale: Mechanical methods, such as the insertion of a Foley catheter, apply continuous pressure to the cervix to promote effacement and dilation.
Which hormonal change contributes to cervical ripening?
A. Increased progesterone.
B. Increased estrogen and prostaglandins.
C. Decreased estrogen and increased oxytocin.
D. Increased oxytocin and progesterone.
B. Increased estrogen and prostaglandins.
Rationale: Cervical ripening is facilitated by hormonal changes, including increased levels of estrogen and prostaglandins, which lead to collagen breakdown and softening of the cervix.
A patient undergoing induction of labor has a Bishop score of 4. What action should the nurse anticipate?
A. Starting oxytocin immediately.
B. Preparing the patient for a cesarean section.
C. Administering a cervical ripening agent.
D. Monitoring the patient for signs of spontaneous labor.
C. Administering a cervical ripening agent.
Rationale: A Bishop score of less than 6 indicates that the cervix is unripe, and cervical ripening agents should be used before initiating labor induction to improve the chances of a successful vaginal birth.
Which statement about the use of nonpharmacologic methods for cervical ripening is accurate?
A. Evening primrose oil and red raspberry leaves are scientifically proven to induce labor safely.
B. Nonpharmacologic methods such as castor oil and enemas have been thoroughly evaluated for efficacy.
C. Nonpharmacologic methods for cervical ripening lack scientific validation for safety and efficacy.
D. Nurses should discourage clients from discussing complementary and alternative methods
C. Nonpharmacologic methods for cervical ripening lack scientific validation for safety and efficacy.
Rationale: Nonpharmacologic methods such as herbal agents, castor oil, and enemas have not been scientifically evaluated for their safety or efficacy in cervical ripening or labor induction.
Which component of sexual intercourse is thought to contribute to cervical ripening?
A. Relaxation of pelvic muscles.
B. Prostaglandins found in semen.
C. Increased oxytocin released from emotional bonding.
D. Decreased uterine pressure.
B. Prostaglandins found in semen.
Rationale: Human semen contains prostaglandins, which can aid in cervical ripening.
What is a potential benefit of breast stimulation as a complementary method for labor induction?
A. It increases endorphin levels.
B. It promotes uterine relaxation.
C. It stimulates the release of oxytocin.
D. It reduces pain perception during contractions.
C. It stimulates the release of oxytocin.
Rationale: Breast stimulation promotes the release of oxytocin, which can lead to uterine contractions.
A nurse is caring for a client interested in using castor oil for labor induction. What is the most appropriate nursing response?
A. “Castor oil is a proven method to induce labor effectively.”
B. “There are no risks associated with using castor oil.”
C. “The safety and effectiveness of castor oil for labor induction have not been scientifically validated.”
D. “Castor oil is recommended by the American College of Obstetricians and Gynecologists for labor induction.”
C. “The safety and effectiveness of castor oil for labor induction have not been scientifically validated.”
Rationale: Castor oil is a nonpharmacologic method whose safety and effectiveness for labor induction have not been validated scientifically.
Which method for labor induction is associated with oxytocin release and prostaglandin exposure?
A. Sexual intercourse with breast stimulation.
B. Enemas.
C. Hot baths.
D. Evening primrose oil.
A. Sexual intercourse with breast stimulation.
Rationale: Sexual intercourse releases prostaglandins in semen, while breast stimulation promotes oxytocin release, both of which aid in labor induction.
What should a nurse emphasize when educating a client about complementary methods of labor induction?
A. These methods are safe and effective for all clients.
B. Risks and benefits of these methods are well-studied and scientifically supported.
C. Complementary methods should always replace pharmacologic induction methods.
D. Clients should discuss the use of any complementary methods with their healthcare provider.
D. Clients should discuss the use of any complementary methods with their healthcare provider.
Rationale: Clients should be advised to consult their healthcare provider regarding the use of complementary methods to ensure safety and appropriate care.
According to a Cochrane review, what is a possible outcome of sexual intercourse with breast stimulation as a labor induction method?
A. Shortened latent phase of labor.
B. Complete dilation of the cervix.
C. Elimination of labor pain.
D. Immediate onset of active labor.
A. Shortened latent phase of labor.
Rationale: The Cochrane review found that sexual intercourse with breast stimulation may shorten the latent phase of labor, although safety issues have not been fully evaluated.
A client asks if red raspberry leaves can be used to induce labor. What should the nurse include in the response?
A. “Red raspberry leaves have been scientifically proven to ripen the cervix.”
B. “The use of red raspberry leaves is safe for everyone and does not require provider consultation.”
C. “The risks and benefits of red raspberry leaves for labor induction are not well-documented.”
D. “This method is a standard practice in labor induction.”
C. “The risks and benefits of red raspberry leaves for labor induction are not well-documented.”
Rationale: The risks and benefits of herbal agents like red raspberry leaves have not been scientifically studied, so they cannot be recommended for labor induction.
Which statement about the loss of the mucus plug during pregnancy is correct?
A. Loss of the mucus plug always indicates the onset of active labor.
B. The mucus plug acts as a barrier to prevent infections in the cervix.
C. Once the mucus plug is lost, it cannot regenerate.
D. The mucus plug is expelled only during delivery.
B. The mucus plug acts as a barrier to prevent infections in the cervix.
Rationale: The mucus plug is a jelly-like barrier in the cervix that helps prevent infections. Its loss does not necessarily indicate imminent labor, and it can regenerate.
What should a nurse include when educating a pregnant client about the loss of the mucus plug?
A. “The loss of the mucus plug is a definitive sign of active labor.”
B. “The mucus plug cannot be replaced once lost, so you should go to the hospital immediately.”
C. “The loss of the mucus plug is normal and does not mean labor will start right away.”
D. “You should contact your healthcare provider immediately after losing the mucus plug.”
C. “The loss of the mucus plug is normal and does not mean labor will start right away.”
Rationale: Losing the mucus plug is a normal part of pregnancy and does not necessarily mean labor is imminent, as the cervix may still take time to prepare for delivery.
Which of the following accurately describes the purpose of membrane stripping as a surgical method to induce labor?
A. To increase uterine contractions by direct stimulation of the uterine wall
B. To detach the amniotic membranes from the cervix to promote cervical ripening
C. To rupture the membranes and expose the cervix to amniotic fluid
D. To decrease prostaglandin levels and reduce labor duration
B. To detach the amniotic membranes from the cervix to promote cervical ripening
Rationale: Membrane stripping involves manual detachment of the amniotic membranes from the cervix to encourage cervical ripening and labor onset.
Which client is at greatest risk for complications following an amniotomy?
A. A client with a breech presentation
B. A client with a Bishop score of 9
C. A client in the latent phase of labor with intact membranes
D. A client with a history of rapid labor
A. A client with a breech presentation
Rationale: Breech presentation increases the risk of umbilical cord prolapse after an amniotomy, making it a contraindication for the procedure.
What is the primary reason for monitoring the fetal heart rate (FHR) immediately following an amniotomy?
A. To identify maternal infection
B. To detect umbilical cord prolapse or compression
C. To determine the duration of labor
D. To evaluate the mother’s tolerance to the procedure
B. To detect umbilical cord prolapse or compression
Rationale: FHR monitoring after an amniotomy is crucial to detect umbilical cord prolapse or compression, which can cause FHR deceleration and jeopardize fetal oxygenation.
Which finding in the amniotic fluid after an amniotomy should prompt immediate notification of the healthcare provider?
A. Clear fluid with a mild odor
B. Blood-streaked fluid
C. Meconium-stained fluid
D. A volume of 500 mL of fluid
C. Meconium-stained fluid
Rationale: Meconium-stained fluid may indicate fetal distress, requiring immediate assessment and intervention to ensure fetal well-being.
What is the most significant risk associated with membrane stripping?
A. Fetal heart rate decelerations
B. Umbilical cord prolapse
C. Maternal or neonatal infection
D. Incomplete placental separation
C. Maternal or neonatal infection
Rationale: Membrane stripping increases the risk of introducing pathogens into the uterus, potentially leading to maternal or neonatal infection.
A nurse is assisting during an amniotomy. Which of the following actions is most critical immediately after the procedure?
A. Administering a uterotonic medication
B. Evaluating maternal discomfort levels
C. Monitoring uterine contraction frequency
D. Assessing fetal heart rate and amniotic fluid characteristics
D. Assessing fetal heart rate and amniotic fluid characteristics
Rationale: After an amniotomy, the nurse must immediately assess the FHR for signs of umbilical cord prolapse or compression and evaluate the amniotic fluid for characteristics indicating complications.
Which prostaglandin agent is FDA-approved for cervical ripening?
A. Dinoprostone (Cervidil)
B. Misoprostol (Cytotec)
C. Oxytocin (Pitocin)
D. Carboprost (Hemabate)
A. Dinoprostone (Cervidil)
Rationale: Dinoprostone (Cervidil) is the only FDA-approved agent for cervical ripening. Misoprostol, while effective, is not FDA-approved for this purpose but is endorsed by ACOG due to its safety and effectiveness.
Which maternal history contraindicates the use of misoprostol (Cytotec) for cervical ripening?
A. Gestational diabetes
B. Previous uterine scar
C. Preterm labor
D. Placenta previa
B. Previous uterine scar
Rationale: Misoprostol is contraindicated for women with prior uterine scars, such as those from a cesarean section, because it increases the risk of uterine rupture.
What is the major adverse effect associated with prostaglandin agents used for cervical ripening?
A. Uterine hyperstimulation
B. Increased risk of infection
C. Delayed cervical ripening
D. Fetal bradycardia
A. Uterine hyperstimulation
Rationale: Prostaglandins can induce excessive uterine contractions, leading to uterine hyperstimulation. This can impair uteroplacental blood flow, increase perinatal morbidity, and potentially lead to uterine rupture.
What is the most appropriate initial dose of misoprostol (Cytotec) for cervical ripening?
A. 25 to 50 mcg
B. 75 to 100 mcg
C. 100 to 200 mcg
D. 10 to 20 mcg
A. 25 to 50 mcg
Rationale: Misoprostol is typically administered at doses of 25 to 50 mcg for cervical ripening. Higher doses increase the risk of uterine hyperstimulation and related complications.
Why is misoprostol not FDA-approved for cervical ripening, despite being widely used?
A. Lack of clinical evidence for its effectiveness
B. High incidence of uterine rupture
C. Its primary indication is gastric ulcer prevention
D. It requires specific administration techniques
C. Its primary indication is gastric ulcer prevention
Rationale: Misoprostol was initially developed and FDA-approved for gastric ulcer prevention. Although it is effective for cervical ripening, its use for this purpose is considered off-label.
Which intervention is most important after administering a prostaglandin agent for cervical ripening?
A. Encouraging ambulation to promote cervical dilation
B. Monitoring fetal heart rate and uterine activity
C. Administering IV fluids to prevent dehydration
D. Inserting a urinary catheter to monitor output
B. Monitoring fetal heart rate and uterine activity
Rationale: Continuous monitoring of fetal heart rate and uterine activity is critical to identify adverse effects such as uterine hyperstimulation or fetal distress.
A nurse is caring for a client receiving dinoprostone gel (Prepidil). Which finding would require immediate action?
A. Mild cramping after administration
B. Cervical dilation of 2 cm
C. Maternal temperature of 99°F
D. Uterine contractions every 2 minutes lasting 90 seconds
D. Uterine contractions every 2 minutes lasting 90 seconds
Rationale: Uterine contractions every 2 minutes lasting 90 seconds indicate uterine hyperstimulation, which can compromise uteroplacental blood flow and lead to fetal distress. Immediate action is required.
Which statement by the nurse demonstrates understanding of prostaglandin use for cervical ripening?
A. “Misoprostol is safe for all women, regardless of obstetric history.”
B. “Dinoprostone is FDA-approved and has minimal risks of adverse effects.”
C. “The primary advantage of prostaglandins is preventing uterine contractions.”
D. “Prostaglandins promote cervical changes and may initiate labor contractions.”
D. “Prostaglandins promote cervical changes and may initiate labor contractions.”
Rationale: Prostaglandins are used for cervical ripening as they promote cervical changes and can stimulate uterine contractions. However, they carry risks such as uterine hyperstimulation.
A nurse observes that uterine contractions have increased in frequency and duration with oxytocin administration. What action should the nurse take first?
A. Stop the oxytocin infusion
B. Increase IV fluids
C. Notify the provider
D. Reposition the client to the left side
A. Stop the oxytocin infusion
Rationale: If uterine hyperstimulation is suspected, the nurse’s first action is to stop the oxytocin infusion to allow the uterus to relax and prevent further fetal compromise. Then, additional interventions can be initiated, such as repositioning and notifying the provider.
Why should oxytocin be titrated cautiously during labor?
A. To prevent prolonged labor
B. To reduce the risk of maternal infection
C. To minimize uterine hyperstimulation and fetal compromise
D. To avoid amniotic fluid embolism
C. To minimize uterine hyperstimulation and fetal compromise
Rationale: Oxytocin must be carefully titrated to minimize the risk of uterine hyperstimulation, which can compromise fetal oxygenation and increase maternal and perinatal morbidity.
What is the typical goal of oxytocin infusion during labor?
A. Continuous uterine contractions lasting 90 seconds
B. Contractions every 2 to 3 minutes lasting 40 to 60 seconds
C. Resting uterine tone above 30 mm Hg
D. Rapid cervical dilation within 1 hour
B. Contractions every 2 to 3 minutes lasting 40 to 60 seconds
Rationale: The goal is to achieve stable contractions every 2 to 3 minutes, each lasting 40 to 60 seconds, allowing for adequate uterine relaxation and fetal oxygenation between contractions.
Which characteristic of oxytocin makes it an effective agent for labor induction?
A. Long half-life of 12 hours
B. Ability to cross the placental barrier
C. Potent, short-acting, and easily titratable
D. Safe for use without monitoring
C. Potent, short-acting, and easily titratable
Rationale: Oxytocin is effective because of its potency, short half-life (1 to 5 minutes), and ease of titration. It is generally well tolerated but requires continuous monitoring due to potential side effects.
Which finding during oxytocin administration requires immediate action?
A. Uterine contractions every 3 minutes lasting 45 seconds
B. Resting uterine tone above 20 mm Hg
C. Clear amniotic fluid
D. Maternal blood pressure of 120/80 mm Hg
B. Resting uterine tone above 20 mm Hg
Rationale: Resting uterine tone above 20 mm Hg can indicate uteroplacental insufficiency and fetal hypoxia, requiring immediate intervention to reduce oxytocin dosage.
What is the primary reason for administering prostaglandins before oxytocin in women with low Bishop scores?
A. To prevent uterine rupture
B. To shorten the duration of labor
C. To decrease the risk of water intoxication
D. To promote cervical ripening and increase the likelihood of successful induction
D. To promote cervical ripening and increase the likelihood of successful induction
Rationale: Prostaglandins are used to ripen the cervix in women with low Bishop scores, significantly enhancing the success of labor induction with oxytocin.
Which symptom indicates water intoxication, a potential side effect of oxytocin?
A. Hypertension and tachycardia
B. Headache and vomiting
C. Bradycardia and diaphoresis
D. Dry mouth and constipation
B. Headache and vomiting
Rationale: Water intoxication due to oxytocin’s antidiuretic effect can result in symptoms such as headache and vomiting.
What is a critical nursing intervention during oxytocin administration?
A. Encourage the patient to void every 30 minutes
B. Maintain the patient in a supine position
C. Discontinue IV fluids to prevent fluid overload
D. Monitor fetal heart rate and uterine activity continuously
D. Monitor fetal heart rate and uterine activity continuously
Rationale: Continuous monitoring of FHR and uterine activity is necessary to identify complications such as uterine hyperstimulation or fetal hypoxia.
How is oxytocin administered during labor induction?
A. Intramuscular injection in the gluteal muscle
B. Intravenous infusion pump piggybacked into the main IV line
C. Subcutaneous injection every 4 hours
D. Oral tablets given every 2 hours
B. Intravenous infusion pump piggybacked into the main IV line
Rationale: Oxytocin is administered via an IV infusion pump, piggybacked into the main intravenous line at the port closest to the insertion site. This allows for precise titration of the medication.
What is the most common adverse effect of oxytocin administration?
A. Uterine rupture
B. Hypotension
C. Uterine hyperstimulation
D. Water intoxication
C. Uterine hyperstimulation
Rationale: The most common adverse effect of oxytocin is uterine hyperstimulation, which can lead to fetal compromise and impaired oxygenation. Continuous fetal heart rate (FHR) monitoring is essential to detect and address this complication.
What should the nurse assess to ensure both the client and fetus are prepared for labor induction?
A. Maternal glucose levels and fetal station
B. Amniotic fluid volume and maternal pain levels
C. Fetal movements and maternal hydration status
D. Cervical dilation, effacement, and fetal well-being
D. Cervical dilation, effacement, and fetal well-being
Rationale: Before labor induction, it is essential to assess the client’s cervical status (dilation and effacement) and ensure fetal well-being through monitoring techniques to determine readiness and the ability to tolerate labor contractions.
Which nursing intervention is essential when evaluating a client before cervical ripening?
A. Administering oxytocin before confirming fetal position
B. Measuring fetal heart tones after prostaglandin insertion
C. Scheduling a cesarean delivery for a Bishop score less than 6
D. Reviewing the client’s history for placenta previa
D. Reviewing the client’s history for placenta previa
Rationale: Rationale: Reviewing the client’s history for contraindications, such as placenta previa, is crucial to prevent complications associated with cervical ripening and labor induction.
What is the primary purpose of calculating the Bishop score before initiating labor induction?
A. To assess maternal vital signs stability
B. To determine the gestational age of the fetus
C. To predict the likelihood of a successful vaginal delivery
D. To identify signs of fetal distress
C. To predict the likelihood of a successful vaginal delivery
Rationale: The Bishop score evaluates cervical readiness for labor and helps predict the likelihood of a successful vaginal delivery. A score over 8 suggests a higher probability of success without cervical ripening.
A nurse is assessing a woman prior to labor induction. Which of the following findings would most likely indicate the need to delay the procedure?
A. Fetal station at -3
B. Bishop score of 9
C. Maternal blood pressure of 135/85 mm Hg
D. Gestational age of 41 weeks
A. Fetal station at -3
Rationale: A fetal station of -3 indicates that the presenting part is still high in the pelvis, which could decrease the likelihood of a successful induction. A low Bishop score (associated with an unfavorable cervix) may require cervical ripening before induction.
Which client history finding would contraindicate labor induction?
A. Gestational diabetes managed with insulin
B. Prolonged ruptured membranes of 24 hours
C. Active genital herpes infection
D. Post-term pregnancy at 41 weeks
C. Active genital herpes infection
Rationale: Active genital herpes infection is a contraindication for labor induction due to the risk of neonatal herpes transmission during vaginal delivery. A cesarean delivery is recommended in such cases.
What is the primary role of the nurse in ensuring informed consent for labor induction?
A. Explaining all aspects of the procedure to the client and her partner
B. Verifying the client has signed the consent form after understanding the procedure
C. Obtaining the client’s verbal agreement before starting induction
D. Determining the client’s Bishop score before obtaining consent
B. Verifying the client has signed the consent form after understanding the procedure
Rationale: The nurse ensures that the client has signed the informed consent form after receiving complete information about the procedure, including risks, benefits, and alternatives, from the healthcare provider. The nurse’s role is to verify understanding, not provide all details of the procedure.
A nurse is preparing a client for labor induction. Which statement by the nurse best explains the procedure?
A. “Labor induction ensures you will have a faster and easier delivery.”
B. “Labor induction involves using various methods to start labor due to medical reasons like high blood pressure or prolonged pregnancy.”
C. “Labor induction is always done using medications such as oxytocin to cause contractions.”
D. “Labor induction will prevent the need for a cesarean section in your case.”
B. “Labor induction involves using various methods to start labor due to medical reasons like high blood pressure or prolonged pregnancy.”
Rationale: The nurse should provide a clear and accurate explanation of labor induction, including its purpose and methods. It is often recommended for specific medical reasons such as elevated blood pressure or prolonged pregnancy.
Which nursing intervention is most important before initiating labor induction?
A. Explaining the risks of cesarean delivery to the client
B. Ensuring that the client’s vital signs are stable
C. Verifying the Bishop score has been assessed and documented
D. Determining the client’s pain tolerance level
C. Verifying the Bishop score has been assessed and documented
Rationale: Ensuring that the Bishop score has been assessed and documented is critical, as it helps predict the success of labor induction and identifies whether cervical ripening is needed.
A client undergoing labor induction asks why her provider recommended this procedure. Which reason would the nurse identify as a possible indication for labor induction?
A. Prolonged pregnancy over 41 weeks
B. Client’s desire for a specific delivery date
C. Maternal age of 35 years or older
D. History of a previous vaginal delivery
A. Prolonged pregnancy over 41 weeks
Rationale: Prolonged pregnancy beyond 41 weeks is a medical indication for labor induction to reduce risks to both the mother and fetus. Personal preference or advanced maternal age alone is not an indication for induction.
What should the nurse include in teaching about methods of labor induction?
A. “Only oxytocin is used to start labor induction.”
B. “Breaking the amniotic sac will soften the cervix.”
C. “Labor induction does not involve medications in most cases.”
D. “Stripping the membranes and using medications are common ways to induce labor.”
D. “Stripping the membranes and using medications are common ways to induce labor.”
Rationale: Stripping the membranes and using medications, such as prostaglandins or oxytocin, are common methods of labor induction. This teaching provides a comprehensive overview of possible approaches.
When preparing to administer misoprostol for cervical ripening, the nurse should ensure the client does not have which condition?
A. Hypertension
B. History of uterine scars
C. Gestational diabetes
D. Polyhydramnios
B. History of uterine scars
Rationale: Misoprostol is contraindicated in women with a history of uterine scars (e.g., from cesarean delivery) due to the increased risk of uterine rupture. Hypertension and gestational diabetes are not contraindications for misoprostol use.
Which nursing action takes priority when administering oxytocin via IV infusion?
A. Monitoring uterine resting tone frequently
B. Administering oxytocin as a primary infusion line
C. Increasing the infusion rate every 10 minutes
D. Discontinuing oxytocin if uterine contractions occur every 5 minutes
A. Monitoring uterine resting tone frequently
Rationale: Monitoring uterine resting tone is critical to ensure the uterus relaxes adequately between contractions and to prevent uteroplacental insufficiency.
Which instruction is most important for the nurse to provide a client receiving oxytocin for labor induction?
A. “Notify me if you feel excessive pressure or pain between contractions.”
B. “You may feel mild cramping as the medication begins to work.”
C. “It is normal to have a decrease in urine output during this procedure.”
D. “This medication will prevent the need for a cesarean section.”
A. “Notify me if you feel excessive pressure or pain between contractions.”
Rationale: Excessive pain or pressure between contractions may indicate uterine hyperstimulation, which requires immediate intervention. Decreased urine output is a sign of water intoxication and is not expected.
What is the expected cervical dilation rate in a client receiving oxytocin for labor induction?
A. 0.5 cm per hour
B. 1 cm per hour
C. 1.5 cm per hour
D. 2 cm per hour
B. 1 cm per hour
Rationale: Satisfactory labor progress during oxytocin administration is typically indicated by cervical dilation of approximately 1 cm per hour. Slower rates may indicate the need for reassessment of the induction plan.
The nurse adjusts the oxytocin infusion rate based on which critical maternal assessment finding?
A. Resting uterine tone
B. Cervical effacement
C. Presence of caput succedaneum
D. Estimated fetal weight
A. Resting uterine tone
Rationale: Resting uterine tone is monitored closely during oxytocin administration to ensure the uterus relaxes between contractions and prevent complications like uteroplacental insufficiency.
Which maternal and fetal assessments should be conducted every 15 minutes during the first stage of labor with oxytocin infusion?
A. Maternal oxygen saturation and fetal head position
B. Maternal vital signs and fetal heart rate
C. Maternal contractions and fetal station
D. Maternal cervical dilation and fetal presentation
B. Maternal vital signs and fetal heart rate
Rationale: Frequent monitoring of maternal vital signs and FHR ensures early identification of complications such as uterine hyperstimulation or fetal distress.
Which action by the nurse can prevent soft tissue obstruction during oxytocin administration for labor induction?
A. Encourage the client to ambulate continuously
B. Perform frequent perineal massages
C. Position the client in a high Fowler’s position
D. Encourage the client to empty her bladder every 2 hours
D. Encourage the client to empty her bladder every 2 hours
Rationale: Encouraging the client to empty her bladder every 2 hours helps prevent soft tissue obstruction and allows for optimal fetal descent.
During the active phase of labor, how frequently should the nurse document the fetal heart rate (FHR) while administering oxytocin?
A. Every 30 minutes
B. Every 20 minutes
C. Every 15 minutes
D. Every 5 minutes
C. Every 15 minutes
Rationale: Continuous FHR monitoring is critical during labor induction with oxytocin. Documentation every 15 minutes during the active phase helps ensure fetal well-being.
Which finding would require immediate discontinuation of oxytocin during labor induction?
A. Contraction duration of 60 seconds
B. Category I FHR pattern
C. Resting uterine tone of 25 mm Hg
D. Category III FHR pattern
D. Category III FHR pattern
Rationale: A category III FHR pattern indicates abnormal fetal status and requires immediate discontinuation of oxytocin to address fetal compromise.
When monitoring a client receiving oxytocin, the nurse notes uterine hyperstimulation. What is the priority nursing action?
A. Increase the oxytocin infusion rate to progress labor
B. Discontinue the oxytocin infusion and notify the healthcare provider
C. Reassess the fetal heart rate every 30 minutes
D. Administer a bolus of IV fluids to reduce uterine activity
B. Discontinue the oxytocin infusion and notify the healthcare provider
Rationale: Uterine hyperstimulation requires immediate discontinuation of oxytocin and notification of the healthcare provider to prevent fetal hypoxia and uterine rupture.
Which is the correct initial nursing action when preparing to administer oxytocin for labor induction?
A. Dilute 10 units of oxytocin in 500 mL of isotonic solution
B. Connect the oxytocin infusion to the primary line
C. Administer oxytocin as a bolus to achieve rapid labor progression
D. Set up the infusion using an IV pump and secondary line
D. Set up the infusion using an IV pump and secondary line
Rationale: Oxytocin is administered via an IV infusion pump on a secondary line to ensure precise titration and safety. Bolus administration is contraindicated as it can lead to uterine hyperstimulation.
A client receiving dinoprostone reports nausea and diarrhea. What should the nurse do first?
A. Discontinue the medication immediately
B. Reassure the client that this is a normal side effect
C. Administer an antiemetic as prescribed
D. Assess the fetal heart rate and maternal vital signs
D. Assess the fetal heart rate and maternal vital signs
Rationale: While nausea and diarrhea are known side effects of dinoprostone, the nurse should first assess maternal and fetal well-being to rule out additional complications before taking further action.
Which adverse effect should the nurse prioritize monitoring when administering oxytocin for labor induction?
A. Maternal hypotension
B. Uterine hyperstimulation
C. Neonatal hypoglycemia
D. Prolonged latent phase of labor
B. Uterine hyperstimulation
Rationale: Uterine hyperstimulation is a critical adverse effect of oxytocin that can impair uteroplacental blood flow and lead to fetal hypoxia or uterine rupture.
What is the most appropriate timing for initiating oxytocin after the administration of misoprostol?
A. Immediately after the last dose of misoprostol
B. At least 2 hours after the last dose
C. At least 4 hours after the last dose
D. The next day after administering misoprostol
C. At least 4 hours after the last dose
Rationale: Oxytocin should be initiated at least 4 hours after the last dose of misoprostol to prevent uterine hyperstimulation and adverse fetal outcomes.
A client receiving oxytocin for labor induction develops signs of water intoxication. Which symptom would the nurse expect to observe?
A. Hyperreflexia
B. Headache and vomiting
C. Hypertension and bradycardia
D. Increased urinary output
B. Headache and vomiting
Rationale: Water intoxication due to oxytocin administration can lead to headache, nausea, vomiting, and confusion due to fluid overload and hyponatremia. Hypertension and increased urinary output are not typical signs.
What is the appropriate nursing action if a client receiving misoprostol develops uterine hyperstimulation?
A. Increase the oxytocin infusion rate to promote uterine relaxation
B. Administer terbutaline to reduce uterine activity
C. Continue monitoring, as this is an expected side effect
D. Apply fundal pressure to assist with fetal descent
B. Administer terbutaline to reduce uterine activity
Rationale: Terbutaline, a tocolytic, is used to manage uterine hyperstimulation and decrease the risk of fetal hypoxia or uterine rupture. Increasing oxytocin would exacerbate hyperstimulation, and fundal pressure is contraindicated in this situation.
Which nursing intervention is most critical when administering dinoprostone for cervical ripening?
A. Administering oxytocin simultaneously with dinoprostone
B. Ensuring the client remains upright for 2 hours after insertion
C. Observing for signs of maternal hypotension
D. Monitoring maternal vital signs and fetal heart rate patterns frequently
D. Monitoring maternal vital signs and fetal heart rate patterns frequently
Rationale: Frequent monitoring of maternal vital signs and fetal heart rate patterns is essential to identify any adverse effects, such as uterine hyperstimulation or fetal compromise. Administering oxytocin simultaneously is contraindicated, and upright positioning is unnecessary for dinoprostone.
A client receiving oxytocin experiences contractions every 90 seconds lasting 90 seconds each. What is the most appropriate intervention?
A. Stop the oxytocin infusion and initiate intrauterine resuscitation
B. Continue monitoring contractions and FHR
C. Decrease the oxytocin infusion rate by 1 mu/min
D. Administer a tocolytic medication to halt contractions
A. Stop the oxytocin infusion and initiate intrauterine resuscitation
Rationale: Contractions occurring every 90 seconds with prolonged durations indicate tachysystole, which can compromise uteroplacental blood flow. The nurse must stop the oxytocin infusion and initiate interventions such as repositioning, oxygen administration, and notifying the provider.
Why is continuous fetal heart rate (FHR) monitoring required during oxytocin administration?
A. To evaluate fetal oxygenation and identify signs of distress
B. To ensure maternal comfort during contractions
C. To determine the progression of cervical dilation
D. To monitor for uterine rupture during labor
A. To evaluate fetal oxygenation and identify signs of distress
Rationale: Continuous FHR monitoring during oxytocin administration is essential to detect fetal distress, which may result from uteroplacental insufficiency caused by uterine hyperstimulation.
What is the nurse’s priority action if tachysystole is detected in a client receiving oxytocin?
A. Increase the oxytocin infusion to progress labor
B. Discontinue oxytocin infusion and notify the provider
C. Administer oxygen via nasal cannula
D. Encourage ambulation to reduce contraction frequency
B. Discontinue oxytocin infusion and notify the provider
Rationale: Tachysystole, defined as excessive uterine contractions, can impair fetal oxygenation. The oxytocin infusion should be discontinued immediately, and the provider notified to prevent complications.
The nurse starts oxytocin at 1 mu/min. According to standard protocols, how frequently should the infusion rate be increased?
A. Every 15 minutes by 2 mu/min
B. Every 20 minutes by 1 mu/min
C. Every 30 to 60 minutes by 1-2 mu/min
D. Every hour by 3 mu/min
C. Every 30 to 60 minutes by 1-2 mu/min
Rationale: Oxytocin infusions are typically increased by 1-2 mu/min every 30 to 60 minutes to achieve adequate contraction patterns without causing uterine tachysystole.
A nurse is preparing to start an oxytocin infusion for labor induction. What is the minimum Bishop score that indicates readiness for induction with oxytocin?
A. 4
B. 6
C. 8
D. 10
C. 8
Rationale: A Bishop score higher than 8 indicates the cervix is favorable for induction with oxytocin, increasing the likelihood of successful labor. Lower scores suggest the need for cervical ripening before oxytocin administration.
A client calls the nurse reporting contractions every 7 minutes lasting 30 seconds, with discomfort only in her lower abdomen. What is the best response by the nurse?
A. “These contractions sound like true labor; go to the hospital.”
B. “You are in early labor; stay home and prepare for delivery.”
C. “This is likely false labor; drink fluids and walk to see if contractions change.”
D. “Call back when contractions are 2–3 minutes apart.”
C. “This is likely false labor; drink fluids and walk to see if contractions change.”
Rationale: Contractions that are irregular, short in duration, and limited to the lower abdomen are indicative of false labor.
How should the nurse advise a client to confirm false labor at home?
A. Rest and avoid walking to minimize contractions.
B. Time contractions to confirm they occur every 4–6 minutes.
C. Assess for cervical changes using a home device.
D. Monitor contraction intensity after drinking fluids and walking.
D. Monitor contraction intensity after drinking fluids and walking.
Rationale: Drinking fluids and walking can help determine whether contractions are false, as false labor contractions often diminish with these actions.
A client reports contractions that begin in her lower back and move to her abdomen. How should the nurse interpret this information?
A. True labor is likely occurring.
B. These are signs of fetal malposition.
C. False labor contractions often behave this way.
D. The client needs immediate intervention for preterm labor.
A. True labor is likely occurring.
Rationale: Discomfort starting in the back and radiating to the abdomen is a hallmark of true labor contractions.
A nurse notes a client’s contractions are irregular and decrease in intensity with ambulation. What should the nurse conclude?
A. The client is experiencing early labor.
B. These are signs of false labor.
C. The client needs immediate medical evaluation.
D. These contractions indicate cervical dilation.
B. These are signs of false labor.
Rationale: Contractions that are irregular and diminish with ambulation are characteristic of false labor.
What should the nurse assess first when a client presents to the hospital with complaints of regular contractions?
A. Frequency, duration, and intensity of contractions
B. Cervical dilation and effacement
C. Fetal station and position
D. Client’s hydration status
A. Frequency, duration, and intensity of contractions
Rationale: Assessing contraction patterns (frequency, duration, and intensity) helps determine whether the client is in true labor, which guides further assessments and interventions.
Which characteristic is most consistent with false labor?
A. Contractions that increase in frequency over time
B. Discomfort radiating from the back to the abdomen
C. Contractions that diminish with walking or position changes
D. Contractions occurring every 5 minutes, lasting 60 seconds
C. Contractions that diminish with walking or position changes
Rationale: False labor contractions typically decrease in intensity or stop with walking, activity, or positional changes.
A client reports contractions that are 4 minutes apart and last 50 seconds but states she can talk through them. What is the nurse’s best response?
A. “You are in active labor; go to the hospital immediately.”
B. “These are Braxton Hicks contractions; drink fluids and rest.”
C. “Call your provider to discuss induction options.”
D. “Stay home until the contractions are so strong you cannot talk during one.”
D. “Stay home until the contractions are so strong you cannot talk during one.”
Rationale: Contractions in true labor become strong enough to prevent conversation during one. The client should monitor for this change before heading to the hospital.
A client in early labor asks when she should go to the hospital. Which response is most appropriate?
A. “Come in when your contractions are 10 minutes apart.”
B. “Stay home until contractions are 5 minutes apart, lasting 45–60 seconds, and strong enough that you can’t talk during one.”
C. “Go to the hospital as soon as contractions start.”
D. “Stay home unless your water breaks.”
B. “Stay home until contractions are 5 minutes apart, lasting 45–60 seconds, and strong enough that you can’t talk during one.”
Rationale: Clients in early labor are typically advised to stay home until contractions are 5 minutes apart, last 45–60 seconds, and are strong enough to limit conversation during one.
A client in her third trimester reports contractions every 5 minutes lasting 60 seconds, with severe back pain radiating to the abdomen. What is the nurse’s best advice?
A. Stay home and hydrate.
B. Take a warm bath to relax.
C. Go to the hospital or birthing center.
D. Lie down and rest to reduce contractions.
C. Go to the hospital or birthing center.
Rationale: Contractions every 5 minutes lasting 60 seconds, combined with discomfort radiating from the back to the abdomen, indicate true labor. The client should proceed to the hospital or birthing center.
What action should a nurse recommend for a client experiencing irregular contractions at 38 weeks gestation?
A. Call the health care provider immediately.
B. Go to the hospital to confirm labor onset.
C. Lie in a supine position to reduce contraction discomfort.
D. Drink fluids and ambulate to assess for changes in contraction intensity.
D. Drink fluids and ambulate to assess for changes in contraction intensity.
Rationale: Irregular contractions that diminish with hydration or activity suggest false labor. Clients can stay home and monitor for changes in intensity or regularity.
Which finding is most indicative of true labor?
A. Irregular contractions with minimal discomfort
B. Contractions felt only in the lower abdomen
C. Contractions that intensify with positional changes
D. Decreased intensity of contractions after hydration
C. Contractions that intensify with positional changes
Rationale: True labor is characterized by contractions that persist and intensify regardless of positional changes or activity.
A nurse assesses a client reporting contractions that diminish with walking and hydration. How should the nurse advise the client?
A. “You should come to the hospital immediately.”
B. “These are signs of true labor, and you should prepare for delivery.”
C. “Lie down and avoid any further activity to prevent labor progression.”
D. “Continue monitoring contractions and stay home unless they become more regular and stronger.”
D. “Continue monitoring contractions and stay home unless they become more regular and stronger.”
Rationale: False labor contractions often decrease with hydration and walking. Clients should stay home unless contractions become regular, stronger, and closer together.
A client at 39 weeks gestation calls the clinic reporting contractions every 6 minutes that last 50 seconds. What additional information should the nurse gather to determine if the client is in true labor?
A. Location of discomfort
B. Presence of vaginal discharge
C. The client’s last meal
D. Fetal movement pattern
A. Location of discomfort
Rationale: In true labor, discomfort begins in the back and radiates to the front of the abdomen. This detail helps distinguish true labor from false labor.
Which statement best differentiates true labor from false labor?
A. True labor contractions are irregular and decrease in intensity with activity.
B. False labor contractions are regular and last 45–60 seconds.
C. True labor contractions increase in strength and continue despite positional changes.
D. False labor contractions start in the back and radiate to the abdomen.
C. True labor contractions increase in strength and continue despite positional changes.
Rationale: True labor contractions become stronger with time and persist regardless of activity or positional changes. False labor contractions are irregular and diminish with activity or rest.
A client is 37 weeks pregnant and reports bright red bleeding after intercourse. How should the nurse respond?
A. “This is normal; avoid intercourse for the rest of the pregnancy.”
B. “Spotting after intercourse is normal in the third trimester.”
C. “Come to the hospital to ensure there are no complications.”
D. “Rest at home and monitor the bleeding.”
C. “Come to the hospital to ensure there are no complications.”
Rationale: Bright red bleeding after intercourse, especially late in pregnancy, could indicate a serious complication, such as placenta previa, and requires immediate evaluation.
A client at 38 weeks gestation reports that her water has broken, and she is not experiencing contractions. What should the nurse instruct her to do?
A. Come to the hospital immediately.
B. Wait at home until contractions begin.
C. Lie down and rest until contractions start.
D. Call the healthcare provider the next day.
A. Come to the hospital immediately.
Rationale: Rupture of membranes requires immediate medical attention to reduce the risk of infection and to assess for labor progression.
A client reports mild spotting after a vaginal exam. What is the appropriate nursing response?
A. Reassure the client that spotting after a vaginal exam is normal.
B. Advise the client to come to the hospital for further evaluation.
C. Instruct the client to rest and monitor for further bleeding.
D. Recommend the client increase fluid intake to reduce the spotting.
A. Reassure the client that spotting after a vaginal exam is normal.
Rationale: Spotting after a vaginal exam is common due to the sensitivity of the cervix. The nurse should reassure the client that this is a normal occurrence.
A pregnant client is experiencing severe pain in the upper abdomen, accompanied by nausea and vomiting. What is the most likely complication?
A. Preeclampsia
B. Placental abruption
C. Acute cholecystitis
D. Ectopic pregnancy
A. Preeclampsia
Rationale: Severe pain in the upper abdomen, along with nausea and vomiting, may indicate preeclampsia, a pregnancy-related condition that requires immediate medical attention.
A client at 37 weeks gestation calls the clinic and reports that her water has broken. The client is not having contractions. What should the nurse recommend?
A. “Stay home and monitor contractions; come in when they begin.”
B. “Come to the hospital immediately for evaluation and monitoring.”
C. “Try walking around to stimulate labor and monitor contractions at home.”
D. “Call your healthcare provider to schedule an induction.”
B. “Come to the hospital immediately for evaluation and monitoring.”
Rationale: Rupture of membranes requires immediate medical evaluation to reduce the risk of infection and assess for signs of labor progression.
A client who is 39 weeks pregnant reports no fetal movement for the past 6 hours. What should the nurse do first?
A. Advise the client to drink cold water and lie down for 30 minutes.
B. Tell the client to wait until the next morning to assess fetal movement.
C. Recommend a visit to the office for a routine checkup.
D. Instruct the client to come to the hospital immediately for fetal monitoring.
D. Instruct the client to come to the hospital immediately for fetal monitoring.
Rationale: No fetal movement for several hours, particularly at term, may indicate fetal distress. The client should come to the hospital immediately for further evaluation and monitoring.
A client calls the hospital and reports contractions every 5 minutes, lasting 60 seconds, but still feels able to talk during contractions. What should the nurse recommend?
A. “Come to the hospital immediately for evaluation.”
B. “Stay at home and continue to monitor your contractions.”
C. “Rest until the contractions become stronger and closer together.”
D. “Call your healthcare provider in the morning for a follow-up appointment.”
B. “Stay at home and continue to monitor your contractions.”
Rationale: Contractions that are regular but not strong enough to impair conversation typically indicate early labor. The client should stay at home and monitor the situation until contractions become stronger.
A client presents with severe headaches, vision changes, and swelling in her hands and feet. What condition should the nurse suspect?
A. Preeclampsia
B. Gestational diabetes
C. Normal pregnancy symptoms
D. Placental abruption
A. Preeclampsia
Rationale: Severe headaches, vision changes, and swelling, particularly in the hands and face, are symptoms of preeclampsia, which requires immediate medical attention.
A pregnant client at 36 weeks gestation reports bright red vaginal bleeding after intercourse. What is the most appropriate nursing action?
A. Advise the client to rest and monitor the bleeding at home.
B. Instruct the client to come to the hospital immediately for evaluation.
C. Reassure the client that this is a normal occurrence in late pregnancy.
D. Tell the client to wait until the bleeding stops and then call the doctor.
B. Instruct the client to come to the hospital immediately for evaluation.
Rationale: Bright red bleeding that is not associated with cervical sensitivity after an exam or intercourse could indicate a serious complication, such as placenta previa or abruptio placenta, and requires immediate evaluation.
A client reports decreased fetal movement, noting that the baby has moved less than 10 times in the last 2 hours when the baby is normally active. What is the nurse’s most appropriate response?
A. “It’s normal for fetal movement to decrease toward the end of pregnancy.”
B. “Try drinking some cold water and lying on your side for 30 minutes and then call me back.”
C. “Contact your healthcare provider for a follow-up appointment.”
D. “It’s important to come to the hospital immediately for fetal monitoring.”
D. “It’s important to come to the hospital immediately for fetal monitoring.”
Rationale: Decreased fetal movement, particularly when it is less than 10 movements in 2 hours, can indicate fetal distress, and the nurse should advise the client to come to the hospital for evaluation.
A client at 39 weeks gestation calls the clinic reporting that her water has broken. She is not having regular contractions. What is the best advice from the nurse?
A. “Go to the hospital immediately regardless of contractions.”
B. “Stay at home until contractions are 5 minutes apart.”
C. “Wait for contractions to begin and call when they are regular.”
D. “Lie down and rest at home until contractions become regular.”
A. “Go to the hospital immediately regardless of contractions.”
Rationale: Rupture of membranes requires immediate medical attention, even if contractions have not started. The nurse should advise the client to go to the hospital immediately.
A client in labor calls the hospital reporting contractions 5 minutes apart, lasting 45 seconds, and they are able to carry on a conversation during contractions. How should the nurse respond?
A. “Stay home and monitor the contractions; come in when they are 4 minutes apart.”
B. “You are in active labor; come to the hospital immediately.”
C. “Stay at home until your contractions become stronger and last for one minute.”
D. “It’s too early for you to come to the hospital; wait until contractions are 2 minutes apart.”
C. “Stay at home until your contractions become stronger and last for one minute.”
Rationale: Contractions in early labor can be irregular and may not cause difficulty in talking. The client should stay home until contractions are stronger and last 60 seconds.
The nurse is assessing a postpartum client 12 hours after delivery. Which finding would the nurse document as normal?
A. The fundus is palpable 2 cm above the umbilicus.
B. The fundus is at the level of the umbilicus and firm.
C. The fundus is midway between the umbilicus and the pubic symphysis.
D. The fundus cannot be palpated in the abdomen.
B. The fundus is at the level of the umbilicus and firm.
Rationale: Within the first 12 hours postpartum, the fundus is typically at the level of the umbilicus and should be firm. A fundus above the umbilicus or not firm may indicate complications such as uterine atony or retained placental fragments.
Which of the following are normal findings during uterine involution? (SATA)
A. The uterus descends approximately 1 cm per day.
B. By 10 days postpartum, the uterus is no longer palpable.
C. The uterus shrinks by 50% within 3 days.
D. Lochia is present as the upper layer of the decidua sloughs off.
E. The fundus remains at the umbilicus for 7 days postpartum.
A. The uterus descends approximately 1 cm per day.
B. By 10 days postpartum, the uterus is no longer palpable.
D. Lochia is present as the upper layer of the decidua sloughs off.
Rationale: Uterine involution involves the uterus descending about 1 cm per day, becoming non-palpable by 10 days postpartum. Lochia occurs due to sloughing of the upper decidual layer. The uterus shrinks by 50% within 1 week, not 3 days, and the fundus should descend daily, not remain at the umbilicus for 7 days.
A nurse is palpating the fundus of a postpartum client on day 5. Where should the fundus normally be located?
A. At the umbilicus
B. 2 cm above the umbilicus
C. 5 cm below the umbilicus
D. Not palpable
C. 5 cm below the umbilicus
Rationale: The uterus descends approximately 1 cm per day postpartum. By day 5, the fundus should be about 5 cm (or 5 fingerbreadths) below the umbilicus, indicating normal uterine involution.
The nurse is assessing a postpartum client 3 days after delivery. The fundus is 2 cm above the umbilicus and soft. What is the nurse’s priority action?
A. Document the finding as normal uterine involution.
B. Encourage the client to breastfeed to stimulate uterine contractions.
C. Notify the healthcare provider of potential uterine atony.
D. Perform a fundal massage and reassess.
D. Perform a fundal massage and reassess.
Rationale: A soft, elevated fundus on day 3 postpartum is abnormal and may indicate uterine atony. The nurse should perform a fundal massage to promote uterine contractions and reassess. If the fundus remains soft, further interventions, such as notifying the healthcare provider, may be necessary.
Which process is primarily responsible for the shrinking of the uterus postpartum?
A. Regeneration of epithelial tissue
B. Sloughing of the decidua
C. Catabolism of uterine muscle cells
D. The release of estrogen and progesterone
C. Catabolism of uterine muscle cells
Rationale: Catabolism is the process by which muscle cells and fibers shrink, leading to the gradual reduction in uterine size postpartum. Regeneration of epithelial tissue and sloughing of the decidua contribute to lochia production, while hormonal changes support the overall process.
A postpartum client asks why she is experiencing lochia. Which explanation by the nurse is most appropriate?
A. “Lochia occurs because the uterus is healing after delivery.”
B. “It is a result of hormonal changes as you adjust to postpartum life.”
C. “Lochia is the shedding of the lower layers of the uterine lining.”
D. “It happens when uterine contractions are too strong.”
A. “Lochia occurs because the uterus is healing after delivery.”
Rationale: Lochia results from the sloughing of the upper layer of the decidua and the regeneration of the uterine epithelium as the uterus heals after delivery. It is a normal part of the postpartum period.
The nurse is reviewing uterine involution with a postpartum client. Which statements by the client indicate a correct understanding? (SATA)
A. “My uterus will shrink by half within the first week.”
B. “The fundus will descend about 1 cm each day.”
C. “My uterus will return to its normal size within 2 days after delivery.”
D. “By 10 days postpartum, my uterus will not be palpable in my abdomen.”
E. “Lochia is a sign that my uterus is not healing properly.”
A. “My uterus will shrink by half within the first week.”
B. “The fundus will descend about 1 cm each day.”
D. “By 10 days postpartum, my uterus will not be palpable in my abdomen.”
Rationale: The uterus shrinks by approximately 50% within the first week, descends about 1 cm per day, and is typically non-palpable by day 10. Lochia is a normal sign of healing, not an indicator of improper healing. It takes several weeks for the uterus to return to its normal size.
A postpartum client’s fundus is palpated two fingerbreadths above the umbilicus on day 3 postpartum. What is the nurse’s priority action?
A. Encourage ambulation to promote uterine descent.
B. Perform a fundal massage to ensure proper contraction.
C. Assist the client in emptying her bladder.
D. Document the finding as normal involution.
C. Assist the client in emptying her bladder.
Rationale: A full bladder can displace the uterus, inhibiting proper involution and increasing the risk of postpartum hemorrhage. Assisting the client to empty her bladder can promote uterine descent. Fundal massage is unnecessary unless the uterus is soft or boggy.
Which of the following factors is most likely to inhibit uterine involution?
A. Breastfeeding
B. A complication-free labor
C. Retained placental fragments
D. Early ambulation
C. Retained placental fragments
Rationale: Retained placental fragments interfere with uterine contraction and healing, leading to subinvolution. Breastfeeding and early ambulation promote uterine involution through stimulation of uterine contractions and improved circulation, while a complication-free labor minimizes uterine trauma.
Which factors facilitate normal uterine involution postpartum? (SATA)
A. Breastfeeding
B. Uterine infection
C. A full bladder
D. Complete expulsion of the placenta
E. Early ambulation
A. Breastfeeding
D. Complete expulsion of the placenta
E. Early ambulation
Rationale: Breastfeeding, complete expulsion of the placenta, and early ambulation facilitate uterine involution by promoting uterine contractions and ensuring the uterus remains empty and active. A full bladder and uterine infection inhibit involution.
The nurse is assessing a postpartum client on day 10. Which finding would indicate normal uterine involution?
A. The fundus is firm and palpable at the umbilicus.
B. The fundus is not palpable in the abdomen.
C. The fundus is two fingerbreadths above the umbilicus.
D. The fundus is midway between the umbilicus and the pubic symphysis.
B. The fundus is not palpable in the abdomen.
Rationale: By day 10 postpartum, the uterus has descended into the true pelvis and is no longer palpable in the abdomen, indicating normal involution. A fundus at or above the umbilicus at this stage is abnormal and suggests subinvolution.
What physiologic process contributes to the shrinkage of myometrial cells during uterine involution?
A. Regeneration of uterine epithelium
B. Contraction of muscle fibers
C. Lochial discharge
D. Catabolism
D. Catabolism
Rationale: Catabolism is the process that shrinks enlarged myometrial cells during uterine involution. Muscle fiber contraction reduces the stretched uterus, and epithelial regeneration replaces the sloughed decidua, while lochial discharge is a byproduct of the process.
A nurse is caring for a postpartum client with subinvolution. Which of the following is most likely contributing to this condition?
A. A large singleton fetus
B. Early ambulation
C. Breastfeeding
D. A complication-free delivery
A. A large singleton fetus
Rationale: Overdistention of uterine muscles, such as from a large singleton fetus, can inhibit involution by decreasing uterine tone and delaying contraction. Early ambulation and breastfeeding promote involution, and a complication-free delivery minimizes uterine trauma.
On day 7 postpartum, a client’s uterus is still palpable above the umbilicus. What complication does the nurse suspect?
A. Retained amniotic membranes
B. Uterine infection
C. Subinvolution of the uterus
D. Postpartum hemorrhage
C. Subinvolution of the uterus
Rationale: Subinvolution occurs when the uterus fails to descend as expected, often due to factors such as retained placental fragments or infection. A uterus above the umbilicus on day 7 is abnormal and indicative of subinvolution.
Which nursing intervention would be most effective in promoting uterine involution in a postpartum client?
A. Encouraging hydration to flush out lochia
B. Teaching the client to massage her uterus daily
C. Advising complete bedrest for 48 hours postpartum
D. Promoting frequent breastfeeding sessions
D. Promoting frequent breastfeeding sessions
Rationale: Breastfeeding stimulates oxytocin release, which promotes uterine contractions and involution. Hydration supports recovery but does not directly impact uterine contraction. Uterine massage is only indicated for a soft or boggy uterus, and bedrest is not recommended unless medically necessary.
Which findings indicate subinvolution in a postpartum client? (SATA)
A. A soft uterus on palpation
B. Fundus at the level of the umbilicus on day 7 postpartum
C. Lochia progressing from rubra to serosa to alba
D. Foul-smelling lochia
E. Heavy vaginal bleeding
A. A soft uterus on palpation
B. Fundus at the level of the umbilicus on day 7 postpartum
D. Foul-smelling lochia
E. Heavy vaginal bleeding
Rationale: Subinvolution may present as a soft uterus, a high fundal height for the postpartum day, foul-smelling lochia (indicative of infection), and heavy bleeding. Proper progression of lochia (rubra to serosa to alba) indicates normal involution.
A postpartum client asks how long it will take for her uterus to return to its nonpregnant state. How should the nurse respond?
A. “Your uterus should return to its original size within 2 weeks.”
B. “The process is complete when your lochia stops.”
C. “Your uterus will return to its original size within 10 days.”
D. “It takes about 6 weeks for your uterus to fully return to its prepregnant size.”
D. “It takes about 6 weeks for your uterus to fully return to its prepregnant size.”
Rationale: Uterine involution typically takes about 6 weeks for the uterus to return to its prepregnant size, although it becomes non-palpable in the abdomen by day 10. The stopping of lochia does not necessarily correlate with the completion of involution.
A nurse is caring for a postpartum client with suspected subinvolution. Which of the following assessment findings is most concerning?
A. Fundus palpable two fingerbreadths below the umbilicus on postpartum day 2
B. Persistent foul-smelling lochia on postpartum day 5
C. Moderate lochia rubra on postpartum day 3
D. Mild cramping and tender uterus on postpartum day 1
B. Persistent foul-smelling lochia on postpartum day 5
Rationale: Persistent foul-smelling lochia may indicate infection, a key cause of subinvolution. By postpartum day 5, lochia should transition to serosa. Fundal height two fingerbreadths below the umbilicus on day 2 is normal, as is moderate lochia rubra on day 3. Mild cramping and tenderness are expected immediately postpartum.
What is the most common cause of subinvolution in the immediate postpartum period?
A. Prolonged labor
B. Overdistension of the uterus
C. Retained placental fragments
D. Polyhydramnios
C. Retained placental fragments
Rationale: Retained placental fragments are the most common cause of subinvolution as they prevent the uterus from fully contracting and returning to its nonpregnant size. The other factors contribute to subinvolution but are less common in the immediate postpartum period.
A nurse is educating a postpartum client on risk factors for subinvolution. Which conditions should the nurse include? (SATA)
A. Full bladder
B. Breastfeeding
C. Polyhydramnios
D. Prolonged labor
E. Large baby
A. Full bladder
C. Polyhydramnios
D. Prolonged labor
E. Large baby
Rationale: A full bladder, polyhydramnios, prolonged labor, and a large baby all contribute to uterine overdistension or incomplete contraction, increasing the risk of subinvolution. Breastfeeding promotes uterine contraction and facilitates involution.
Which statement by a postpartum client indicates the need for further education regarding subinvolution?
A. “A full bladder can prevent my uterus from contracting properly.”
B. “Having a large baby could make it harder for my uterus to return to normal.”
C. “Breastfeeding increases my risk of subinvolution.”
D. “Retained placental fragments could delay my uterus from shrinking.”
C. “Breastfeeding increases my risk of subinvolution.”
Rationale: Breastfeeding stimulates oxytocin release, which promotes uterine contraction and reduces the risk of subinvolution. The other statements correctly identify risk factors for subinvolution.
A nurse notes that a postpartum client’s fundus is soft and located two fingerbreadths above the umbilicus on day 5. What is the nurse’s priority action?
A. Assess for signs of infection.
B. Assist the client to breastfeed.
C. Perform a fundal massage.
D. Prepare the client for an ultrasound.
C. Perform a fundal massage.
Rationale: A soft (boggy) uterus requires immediate fundal massage to stimulate contraction and prevent hemorrhage. Once stabilized, further assessment and interventions, such as breastfeeding or imaging, can be performed as needed.
Which findings would the nurse expect in a postpartum client experiencing subinvolution? (SATA)
A. Lochia rubra persisting beyond the normal timeframe
B. Fundus palpable above the umbilicus on day 7
C. Firm uterus on palpation
D. Decreased lochia flow
E. Heavy vaginal bleeding
A. Lochia rubra persisting beyond the normal timeframe
B. Fundus palpable above the umbilicus on day 7
E. Heavy vaginal bleeding
Rationale: Persistent lochia rubra, a high fundal height, and heavy vaginal bleeding are indicative of subinvolution. A firm uterus and decreased lochia flow are signs of normal involution.
A postpartum client has a full bladder and subinvolution. Which complication is the client most at risk for if the bladder is not addressed?
A. Postpartum hemorrhage
B. Endometritis
C. Pelvic organ prolapse
D. Urinary tract infection
A. Postpartum hemorrhage
Rationale: A full bladder displaces the uterus and inhibits contractions, increasing the risk of postpartum hemorrhage. While endometritis and urinary tract infections are possible postpartum complications, they are not directly caused by subinvolution and a full bladder.
A postpartum client asks why her cervix feels different during a self-examination. What is the best response by the nurse?
A. “The cervix returns to its pre-pregnant state immediately after birth.”
B. “The external os changes from a round shape to a jagged slit after vaginal delivery.”
C. “The cervical os remains fully dilated for several weeks after birth.”
D. “Your cervix will not change in appearance after childbirth.”
B. “The external os changes from a round shape to a jagged slit after vaginal delivery.”
Rationale: After childbirth, the external os changes from a round shape to a jagged slit, which is a normal postpartum finding.
The nurse is assessing a postpartum client 24 hours after delivery. Which cervical finding is expected at this time?
A. The cervix is soft and completely dilated.
B. The cervix is firm and has regained its pre-pregnancy shape.
C. The cervix is firming up and shortening but remains slightly dilated.
D. The cervix is fully closed and appears round.
C. The cervix is firming up and shortening but remains slightly dilated.
Rationale: Within 12 to 18 hours postpartum, the cervix begins to firm up, shorten, and close gradually but remains slightly dilated.
A postpartum nurse is educating a client on cervical changes after delivery. Which statement indicates the need for further teaching?
A. “The cervix is soft immediately after birth and becomes firm over the next day.”
B. “The cervical os will return to its pre-pregnancy round shape after childbirth.”
C. “The cervix gradually closes after being dilated to 10 cm during labor.”
D. “The external os appears as a jagged slit after childbirth, which is normal.”
B. “The cervical os will return to its pre-pregnancy round shape after childbirth.”
Rationale: The cervical os does not return to its pre-pregnancy round shape; instead, it appears as a jagged slit postpartum.
The nurse is monitoring a postpartum client and notes that her cervix is soft and slightly open. What is the priority nursing action?
A. Assess the client’s fundus for firmness.
B. Notify the healthcare provider immediately.
C. Educate the client that this is a normal finding.
D. Perform a sterile cervical exam to assess dilation.
C. Educate the client that this is a normal finding.
Rationale: It is normal for the cervix to be soft and slightly open immediately after birth. Over the next 12 to 18 hours, it gradually firms and closes.
The nurse is educating a postpartum client about cervical healing. Which statement indicates the client understands the changes to her cervix?
A. “My cervix will return to its pre-pregnancy appearance by 2 weeks postpartum.”
B. “My cervix will remain bruised and edematous for the entire postpartum period.”
C. “The internal and external os both completely return to their original shape after childbirth.”
D. “The external os of my cervix will never regain its pre-pregnancy circular shape.”
A. “The external os of my cervix will never regain its pre-pregnancy circular shape.”
Rationale: The external cervical os does not regain its pre-pregnancy circular shape but instead appears as a jagged slit postpartum.
During a postpartum assessment, the nurse notes that the client’s cervix is edematous and partly dilated. What is the best action by the nurse?
A. Notify the healthcare provider of abnormal findings.
B. Document the findings as normal in the first postpartum days.
C. Perform a sterile speculum examination to rule out trauma.
D. Educate the client that cervical healing will take only a few days.
B. Document the findings as normal in the first postpartum days.
Rationale: It is normal for the cervix to remain edematous, bruised, and partly dilated immediately after childbirth. This does not require intervention.
When educating a postpartum client, which timeframe should the nurse provide for the cervix to return to its prepregnant state?
A. 1 week postpartum
B. 2 weeks postpartum
C. 4 weeks postpartum
D. 6 weeks postpartum
D. 6 weeks postpartum
Rationale: The cervix typically returns to its prepregnant state by 6 weeks postpartum.
A nurse is teaching a group of new nurses about postpartum cervical changes. Which statement by a new nurse indicates a need for further teaching?
A. “The external os changes from a circular to a jagged slit-like shape.”
B. “The cervix is edematous and easily distensible immediately after childbirth.”
C. “The internal cervical os fully closes by 2 weeks postpartum.”
D. “The external cervical os completely closes and regains its prepregnancy appearance.”
D. “The external cervical os completely closes and regains its prepregnancy appearance.”
Rationale: The external os does not completely close or regain its prepregnancy circular appearance but instead remains wider and slit-like.
A nurse is assessing the vaginal area of a postpartum client. Which finding would be considered normal in the first few days following childbirth?
A. Absence of vaginal rugae and edematous vaginal walls
B. Complete reappearance of vaginal rugae
C. Normal thickness of the vaginal wall
D. Fully restored vaginal epithelium
A. Absence of vaginal rugae and edematous vaginal walls
Rationale: In the early postpartum period, the vaginal walls are edematous, and rugae are absent. The vaginal epithelium and thickness take 6 to 10 weeks to fully restore.
A nurse is educating a postpartum client about changes to her vagina. Which of the following statements by the client indicates that she understands the information?
A. “It will take about 1 week for the rugae in my vagina to reappear.”
B. “My vaginal walls will remain edematous for several weeks.”
C. “The vaginal epithelium will be restored to its normal state in about 2 weeks.”
D. “The vaginal walls should regain their thickness by 3 weeks postpartum.”
B. “My vaginal walls will remain edematous for several weeks.”
Rationale: The vaginal walls appear edematous immediately after childbirth, and rugae begin to reappear by 3 to 4 weeks, with complete epithelium restoration occurring in 6 to 10 weeks.
A postpartum client is concerned about her vaginal appearance. The nurse explains that the vaginal rugae are absent immediately after birth but will begin to return. When can the client expect to see vaginal rugae reappear?
A. 1 week
B. 3 to 4 weeks
C. 6 weeks
D. 10 weeks
B. 3 to 4 weeks
Rationale: Vaginal rugae begin to reappear around 3 to 4 weeks postpartum.
A postpartum client who had a vaginal birth is asking about the recovery of her vaginal walls. Which of the following would the nurse tell the client?
A. “Your vaginal walls will regain thickness in about 6 weeks.”
B. “The vaginal walls will take 10 weeks to regain their normal thickness.”
C. “You may notice thinning of the vaginal walls for 4 to 6 weeks.”
D. “The vaginal walls will remain stretched and thin for the entire postpartum period.”
A. “Your vaginal walls will regain thickness in about 6 weeks.”
Rationale: The vaginal walls begin to regain thickness and return to a more normal state around 6 weeks postpartum.
A postpartum client has multiple small lacerations in her vaginal area. Which statement by the nurse best explains this finding?
A. “These small lacerations are abnormal and require immediate treatment.”
B. “The lacerations will heal in 1 to 2 days without further treatment.”
C. “Small lacerations are an indication of a more serious complication, such as infection.”
D. “These small lacerations are normal and common after childbirth.”
D. “These small lacerations are normal and common after childbirth.”
Rationale: Multiple small lacerations are common in the vaginal area after childbirth and typically heal without complications.
A postpartum client inquires about the healing process of her vagina. The nurse explains that the vaginal epithelium will be restored gradually. How long does it typically take for the vaginal epithelium to fully restore?
A. 1 to 2 weeks
B. 3 to 4 weeks
C. 6 to 10 weeks
D. 12 weeks
C. 6 to 10 weeks
Rationale: The vaginal epithelium is typically restored over a period of 6 to 10 weeks postpartum.
A nurse is assessing a postpartum client and notices that the vaginal mucosa is thin, relaxed, and edematous with few rugae. Which of the following is the most appropriate action by the nurse?
A. Administer estrogen therapy to restore vaginal tone.
B. Reassure the client that these changes are normal and temporary.
C. Prepare for a surgical intervention to restore the vaginal tone.
D. Document the findings as abnormal and notify the physician.
B. Reassure the client that these changes are normal and temporary.
Rationale: It is normal for the vaginal mucosa to be thin, relaxed, and edematous with few rugae shortly after birth. These changes resolve over time as the body heals, and the mucosa thickens and rugae return in approximately 3 weeks.
A postpartum client asks how long it will take for her vagina to return to its pre-pregnancy size. What is the nurse’s best response?
A. “Your vagina should return to its pre-pregnancy size within 3 weeks.”
B. “It will take about 6 to 8 weeks for your vagina to return to its pre-pregnancy size, although it will always be a bit larger.”
C. “Your vagina will remain larger than its pre-pregnancy size for the entire postpartum period.”
D. “Your vagina will return to its pre-pregnancy size in about 12 weeks.”
B. “It will take about 6 to 8 weeks for your vagina to return to its pre-pregnancy size, although it will always be a bit larger.”
Rationale: The vagina generally returns to its approximate pre-pregnancy size within 6 to 8 weeks postpartum but will always be slightly larger than before pregnancy.
A nurse is educating a postpartum client about the changes in her vaginal area. Which statement indicates the client understands the information?
A. “My vagina will return to its pre-pregnancy size by 3 weeks postpartum.”
B. “The vaginal mucosa will thicken and rugae will return within about 3 weeks after birth.”
C. “I can expect my vagina to remain the same size and tone as it was before pregnancy.”
D. “I will experience vaginal dryness and discomfort until my menstruation returns.”
D. “I will experience vaginal dryness and discomfort until my menstruation returns.”
Rationale: Many women experience localized dryness and coital discomfort (dyspareunia) until menstruation returns. Water-soluble lubricants can help reduce discomfort during intercourse.
A postpartum client is concerned about changes in her vaginal area. Which of the following is an expected finding shortly after childbirth?
A. Thickened vaginal mucosa and return of rugae
B. Decreased vascularity and a smaller vaginal opening
C. Edematous, relaxed vaginal mucosa with few rugae
D. Increased vaginal tone and reduced vaginal size
C. Edematous, relaxed vaginal mucosa with few rugae
Rationale: Immediately after childbirth, the vaginal mucosa is edematous, relaxed, and thin with few rugae. This is a normal finding in the early postpartum period.
A postpartum client reports perineal discomfort and bruising. Which of the following is the most likely cause of these symptoms?
A. Infection at the perineal site
B. Trauma from childbirth, including stretching and possible laceration
C. Prolonged perineal care
D. Inadequate healing of the perineum
B. Trauma from childbirth, including stretching and possible laceration
Rationale: The perineum often experiences trauma during childbirth due to stretching to accommodate the fetal head. This trauma typically results in bruising, edema, and sometimes lacerations or hematomas. Healing usually takes 4-6 weeks.
A postpartum client who delivered vaginally is concerned about perineal healing. The nurse explains that the perineum may be edematous and bruised but should heal within a few weeks. Which of the following is the most appropriate nursing intervention to promote healing and comfort for this client?
A. Recommend the use of Witch Hazel (Tuck’s) and Dermaplast spray for relief.
B. Instruct the client to avoid perineal care for 2 weeks to prevent irritation.
C. Suggest frequent pelvic floor exercises to speed healing.
D. Encourage the client to refrain from sitting for long periods to prevent pressure.
A. Recommend the use of Witch Hazel (Tuck’s) and Dermaplast spray for relief.
Rationale: Witch Hazel (Tuck’s) and Dermaplast spray are often used to provide relief from perineal discomfort, bruising, and edema. Proper perineal care with a spray bottle is also important for hygiene.
A nurse is teaching a postpartum client about perineal care. Which of the following instructions should the nurse include to promote healing and reduce discomfort?
A. “Avoid using any topical products on the perineum until it is fully healed.”
B. “Increase activity and pelvic exercises to encourage blood flow to the perineal area.”
C. “Use a hot compress directly on the perineum to reduce swelling.”
D. “Gently clean the perineum with warm water using a peri bottle after each void.”
D. “Gently clean the perineum with warm water using a peri bottle after each void.”
Rationale: Gentle cleaning of the perineum with a peri bottle using warm water helps maintain hygiene while reducing the risk of infection. Avoiding harsh cleaning methods is important to prevent further irritation.
A postpartum client is experiencing severe perineal pain and swelling. Upon assessment, the nurse observes bruising, edema, and a small hematoma in the perineal area. What is the most appropriate nursing action?
A. Administer an analgesic and apply ice to the perineal area.
B. Perform a pelvic exam to rule out infection.
C. Encourage the client to sit in a warm bath to reduce swelling.
D. Document the findings and wait for the perineum to heal on its own.
A. Administer an analgesic and apply ice to the perineal area.
Rationale: Ice can be applied to the perineal area to reduce swelling and pain. Analgesics can be used for comfort. Hematomas and bruising are expected after childbirth and usually resolve with proper care.
A nurse is caring for a postpartum client who experienced a vaginal delivery. Which of the following is an expected finding during the first few weeks after birth?
A. Complete resolution of perineal swelling and bruising by day 2
B. Complete healing of lacerations by day 7
C. Perineal edema and bruising that will gradually improve over the next few weeks
D. Persistent perineal discomfort with no improvement by week 6
C. Perineal edema and bruising that will gradually improve over the next few weeks
Rationale: Perineal edema, bruising, and trauma (including lacerations) are common following vaginal delivery and typically heal over the course of 4-6 weeks. Some degree of discomfort may persist during this period.
A nurse is providing discharge instructions to a postpartum client who delivered vaginally. Which of the following statements by the client indicates the need for further teaching about perineal care?
A. “I will apply Witch Hazel (Tuck’s) pads for relief of discomfort.”
B. “I will clean the perineum with soap and water after every void.”
C. “I will use the peri bottle to rinse the area with warm water after each void.”
D. “I will avoid sitting for long periods to reduce pressure on the perineum.”
B. “I will clean the perineum with soap and water after every void.”
Rationale: The client should use a peri bottle with warm water to rinse the perineum, not soap and water, to avoid irritation. The other statements are appropriate and indicate proper understanding of perineal care.
A postpartum client with a perineal laceration expresses concerns about the healing process. The nurse explains that healing may take up to 4 to 6 months. Which of the following factors can delay perineal healing?
A. Inadequate use of sitz baths
B. Limited ambulation after childbirth
C. Increased fluid intake
D. Infection at the perineal site
D. Infection at the perineal site
Rationale: Infection at the perineal site, such as endometritis or cellulitis, can delay the healing process. Other factors like limited ambulation or inadequate self-care may contribute but are not as likely to cause significant delay as infection.
A nurse is discussing perineal care with a postpartum client who had a vaginal delivery. Which of the following measures should the nurse recommend to alleviate perineal discomfort and promote healing?
A. Avoid using ice packs on the perineum to prevent tissue damage.
B. Perform pelvic floor muscle training (PFMT) exercises immediately after delivery.
C. Increase physical activity to improve blood circulation to the perineum.
D. Use witch hazel pads, sitz baths, and anesthetic sprays for pain relief.
D. Use witch hazel pads, sitz baths, and anesthetic sprays for pain relief.
Rationale: Witch hazel pads, sitz baths, and anesthetic sprays can effectively relieve perineal pain and promote healing. Pelvic floor muscle training (PFMT) should not begin immediately after delivery due to the need for proper recovery time.
A postpartum client who sustained a perineal laceration during childbirth complains of difficulty with bowel movements. Which of the following interventions should the nurse recommend to relieve discomfort during defecation?
A. Increase fiber intake and ensure adequate hydration to prevent constipation.
B. Apply a cold compress to the perineum before defecation.
C. Avoid using a peri bottle after bowel movements to reduce irritation.
D. Perform pelvic floor muscle exercises to improve bowel function.
A. Increase fiber intake and ensure adequate hydration to prevent constipation.
Rationale: Increasing fiber intake and staying hydrated can help prevent constipation, reducing strain during bowel movements, which may cause discomfort at the laceration site. Cold compresses are typically used for immediate pain relief, not specifically for bowel movements.
A postpartum client asks about the expected timeline for healing of a perineal laceration after childbirth. Which of the following statements by the nurse is accurate?
A. “Most perineal lacerations heal within the first two weeks without complications.”
B. “Healing of a perineal laceration can take 4 to 6 months, especially if complications arise.”
C. “Pelvic floor muscle training (PFMT) exercises can accelerate the healing process immediately after birth.”
D. “The perineum usually returns to normal tone within one month postpartum.”
B. “Healing of a perineal laceration can take 4 to 6 months, especially if complications arise.”
Rationale: Perineal lacerations typically take 4 to 6 months to heal fully, especially in the presence of complications. PFMT exercises help strengthen the pelvic floor but are not typically recommended immediately after childbirth.
A postpartum client asks the nurse about preventing pelvic floor dysfunction. Which of the following recommendations should the nurse provide?
A. Perform pelvic floor muscle training (PFMT) exercises immediately after childbirth.
B. Avoid physical activity for the first 6 months to allow the pelvic floor to rest.
C. Practice pelvic floor muscle training (PFMT) exercises regularly to improve muscle tone.
D. Perform exercises that focus on abdominal strengthening rather than pelvic floor exercises.
C. Practice pelvic floor muscle training (PFMT) exercises regularly to improve muscle tone.
Rationale: Regular pelvic floor muscle training (PFMT) exercises help improve pelvic floor muscle tone, strengthen the perineal muscles, and prevent dysfunction. Starting these exercises once the client is ready can help promote healing and restore pelvic floor strength.
A postpartum patient has a heart rate of 55 bpm on day 2 postpartum. Which of the following actions is MOST appropriate for the nurse?
A. Document the finding as bradycardia and monitor for further changes.
B. Notify the healthcare provider immediately.
C. Administer intravenous fluids for suspected dehydration.
D. Assess for signs of postpartum hemorrhage.
A. Document the finding as bradycardia and monitor for further changes.
Rationale: Bradycardia (40–60 bpm) during the first 2 weeks postpartum is an expected finding due to the increased blood flow back to central circulation after delivery. This adaptation allows the heart to pump efficiently at a slower rate.
A nurse is caring for a postpartum patient with a heart rate of 105 bpm and reports feeling weak and dizzy. Which of the following should the nurse assess first?
A. Blood pressure and uterine tone
B. Fluid intake and urine output
C. Hemoglobin and hematocrit levels
D. Respiratory rate and oxygen saturation
A. Blood pressure and uterine tone
Rationale: Tachycardia in a postpartum patient may indicate hypovolemia or hemorrhage. Assessing blood pressure and uterine tone will help identify potential causes such as uterine atony or excessive bleeding.
A postpartum patient reports a severe headache and has a blood pressure of 160/100 mmHg. What is the nurse’s PRIORITY action?
A. Notify the healthcare provider immediately for evaluation of preeclampsia.
B. Encourage the patient to rest and reassess blood pressure in 1 hour.
C. Administer pain medication and monitor for resolution of the headache.
D. Assess the patient’s fundus and lochia for signs of hemorrhage.
A. Notify the healthcare provider immediately for evaluation of preeclampsia.
Rationale: A significant increase in blood pressure accompanied by headache may indicate postpartum preeclampsia, a potentially life-threatening condition. Immediate notification of the healthcare provider is critical for further evaluation and treatment.
The nurse is caring for a postpartum patient whose blood pressure has dropped significantly since delivery. Which additional finding would support a diagnosis of uterine hemorrhage?
A. Bradycardia (50 bpm)
B. Firm uterine fundus
C. Increased lochia with large clots
D. Normal respiratory rate
C. Increased lochia with large clots
Rationale: A drop in blood pressure combined with increased lochia and the passage of large clots is indicative of hemorrhage. Bradycardia is not consistent with hemorrhage, and a firm fundus would rule out uterine atony.
Which statement made by a postpartum patient indicates the need for further teaching regarding blood pressure changes?
A. “My blood pressure should return to normal by about 6 weeks after giving birth.”
B. “If my blood pressure is high and I have a headache, I should call my doctor.”
C. “It’s normal for my blood pressure to drop a lot during the first few days.”
D. “I should monitor for dizziness if my blood pressure gets too low.”
C. “It’s normal for my blood pressure to drop a lot during the first few days.”
Rationale: While a slight decrease in blood pressure is expected postpartum, a significant drop is not normal and may indicate complications such as hemorrhage or infection. This statement reflects a misunderstanding of normal postpartum changes.
A postpartum patient with tachycardia and a slightly elevated blood pressure is found to have a firm uterus and moderate lochia. What is the nurse’s next step?
A. Increase the patient’s fluid intake and monitor for dehydration.
B. Notify the healthcare provider for suspected preeclampsia.
C. Reassess the patient’s heart rate in 1 hour and document findings.
D. Assess for additional signs of infection, such as fever or localized pain.
D. Assess for additional signs of infection, such as fever or localized pain.
Rationale: Tachycardia and slightly elevated blood pressure in the absence of hemorrhage may indicate infection. Additional assessment for fever, localized pain, or other signs of infection is essential.
A postpartum patient has a blood pressure of 90/60 mmHg and reports feeling lightheaded when standing. Which nursing intervention is MOST appropriate?
A. Encourage the patient to ambulate with assistance to promote circulation.
B. Administer IV fluids to address potential hypovolemia.
C. Reassess blood pressure after the patient rests in a supine position.
D. Monitor the patient’s hematocrit level for signs of hemorrhage.
B. Administer IV fluids to address potential hypovolemia.
Rationale: A blood pressure of 90/60 mmHg with lightheadedness suggests hypovolemia, which may be caused by hemorrhage or dehydration. Administering IV fluids is a priority intervention to stabilize the patient.
A nurse notes a postpartum patient has difficulty voiding and profuse vaginal bleeding. What complication should the nurse suspect?
A. Postpartum hemorrhage due to uterine atony
B. Postpartum hemorrhage due to uterine displacement
C. UTI due to prolonged labor
D. Retention of urine caused by uterine overdistention
B. Postpartum hemorrhage due to uterine displacement
Rationale: A full bladder can displace the uterus, preventing it from contracting effectively and leading to excessive vaginal bleeding. Emptying the bladder is critical to resolving this issue.
A postpartum patient reports passing a large amount of urine during the first 24 hours after delivery. What should the nurse do?
A. Reassure the patient that this is expected postpartum diuresis.
B. Restrict fluid intake to prevent overhydration.
C. Notify the healthcare provider of possible polyuria.
D. Assess for signs of fluid retention or edema.
A. Reassure the patient that this is expected postpartum diuresis.
Rationale: Postpartum diuresis is a normal process where the body eliminates excess fluid retained during pregnancy, often resulting in increased urination.
A postpartum patient is experiencing difficulty voiding and reports urinating small amounts frequently. Which complication should the nurse suspect?
A. Urinary tract infection (UTI)
B. Postpartum hemorrhage
C. Urinary retention with overflow
D. Bladder prolapse
C. Urinary retention with overflow
Rationale: Frequent voiding of small amounts (<150 mL) suggests urinary retention with overflow. This condition requires catheterization to empty the bladder and restore tone.
The nurse assesses a postpartum patient and notes the uterus is displaced to the right. What should the nurse do FIRST?
A. Assess for signs of postpartum hemorrhage.
B. Perform a straight catheterization.
C. Massage the fundus to stimulate uterine contraction.
D. Assist the patient to void.
D. Assist the patient to void.
Rationale: A uterus displaced to the right is often caused by bladder distention. Assisting the patient to void may correct the displacement and reduce the risk of complications, such as postpartum hemorrhage.
A postpartum patient received an epidural during labor and is unable to feel the sensation to void. What is the patient MOST at risk for?
A. Uterine rupture
B. Postpartum hemorrhage
C. UTI due to frequent voiding
D. Perineal hematoma
B. Postpartum hemorrhage
Rationale: Inability to void can lead to urinary retention, bladder distention, and uterine displacement, which may prevent proper uterine contraction and increase the risk of postpartum hemorrhage.
The nurse is caring for a postpartum patient who is voiding less than 150 mL at a time and has a firm, midline uterus. What is the PRIORITY nursing action?
A. Increase oral fluid intake.
B. Perform a bladder scan to assess for urinary retention.
C. Document the findings as normal postpartum diuresis.
D. Administer oxytocin to promote uterine contraction.
B. Perform a bladder scan to assess for urinary retention.
Rationale: Small voids (<150 mL) may indicate urinary retention with overflow. A bladder scan can confirm retention and guide further intervention, such as catheterization.
Which of the following factors contributes to postpartum diuresis? Select all that apply.
A. Declining levels of oxytocin
B. Decreasing aldosterone production
C. Retention of extra fluids during pregnancy
D. Increased antidiuretic hormone levels
E. Administration of IV fluids during labor
A. Declining levels of oxytocin
B. Decreasing aldosterone production
C. Retention of extra fluids during pregnancy
E. Administration of IV fluids during labor
Rationale: Postpartum diuresis results from a decline in oxytocin (antidiuretic effect), decreased aldosterone production (increased sodium and water excretion), retained fluids from pregnancy, and IV fluid administration during labor.
A postpartum patient reports burning on urination, and the nurse notes generalized swelling around the urinary meatus. What is the MOST appropriate action?
A. Encourage fluid intake and reassess in 4 hours.
B. Administer prescribed antibiotics to treat a UTI.
C. Assess for perineal lacerations and hematomas.
D. Perform a straight catheterization to check for retention.
C. Assess for perineal lacerations and hematomas.
Rationale: Burning during urination and swelling near the urinary meatus may indicate perineal lacerations or hematomas, which can impede urination and increase discomfort.
A nurse is educating a postpartum patient about bladder tone recovery. Which statement by the patient indicates a need for further teaching?
A. “I should empty my bladder regularly to avoid distention.”
B. “My bladder tone will recover within 6 weeks after delivery.”
C. “I don’t need to worry about my bladder if I feel like I’m urinating enough.”
D. “Swelling around the urinary meatus might make it harder to urinate.”
C. “I don’t need to worry about my bladder if I feel like I’m urinating enough.”
Rationale: Postpartum urinary retention can occur even if the patient is voiding frequently. The nurse should emphasize the importance of monitoring voiding patterns and bladder emptying.
What postpartum condition is MOST likely to result in a UTI?
A. Bladder distention and incomplete emptying
B. Increased aldosterone levels
C. Excessive diuresis during the first 24 hours postpartum
D. Perineal lacerations and hematomas
A. Bladder distention and incomplete emptying
Rationale: Bladder distention and incomplete emptying can lead to urinary stasis, increasing the risk of a UTI.
A nurse is monitoring a postpartum patient for signs of uterine atony. Which urinary system adaptation increases the risk of this condition?
A. Increased diuresis during the first week postpartum
B. Urinary retention and bladder distention
C. Decreased glomerular filtration rate
D. Normal dilation of the ureters and renal pelvis
B. Urinary retention and bladder distention
Rationale: Urinary retention and bladder distention can displace the uterus and prevent it from contracting effectively, leading to uterine atony and postpartum hemorrhage.
Which patient is MOST at risk for urinary retention postpartum?
A. A patient who received a spinal block during labor
B. A patient who had a spontaneous vaginal delivery without anesthesia
C. A patient who voided 200 mL within 4 hours postpartum
D. A patient with a history of frequent UTIs during pregnancy
A. A patient who received a spinal block during labor
Rationale: A spinal block can impair neural function, reducing bladder sensation and increasing the risk of urinary retention postpartum.
The nurse notes a postpartum patient has an elevated glomerular filtration rate (GFR) 48 hours after delivery. What should the nurse do?
A. Document this finding as normal.
B. Administer IV fluids to maintain renal perfusion.
C. Contact the healthcare provider immediately.
D. Assess for signs of renal impairment.
A. Document this finding as normal.
Rationale: Elevated GFR and renal plasma flow typically persist for a few days postpartum as the body clears excess fluid.
A postpartum patient is concerned about urinary incontinence. Which teaching point should the nurse include?
A. “Incontinence is a permanent condition after childbirth.”
B. “Kegel exercises can help improve bladder tone.”
C. “Avoid drinking too much water to reduce leakage.”
D. “You should avoid walking to prevent stress on the bladder.”
B. “Kegel exercises can help improve bladder tone.”
Rationale: Kegel exercises strengthen pelvic floor muscles, aiding in the recovery of bladder tone and reducing urinary incontinence.
A postpartum patient has a full bladder and reports difficulty voiding. The nurse notes excessive vaginal bleeding. What is the PRIORITY nursing action?
A. Perform fundal massage to stimulate uterine contraction.
B. Encourage the patient to drink fluids to promote voiding.
C. Assist the patient to the bathroom to empty the bladder.
D. Catheterize the patient to empty the bladder immediately.
D. Catheterize the patient to empty the bladder immediately.
Rationale: A full bladder can displace the uterus, preventing proper contraction and causing excessive bleeding. Immediate bladder emptying is necessary to restore uterine tone.
Which patient is at the HIGHEST risk for developing a postpartum urinary tract infection (UTI)?
A. A patient who delivered vaginally with no interventions
B. A patient who had a cesarean birth with a Foley catheter in place
C. A patient who experienced profuse postpartum diuresis
D. A patient who is voiding small amounts frequently
B. A patient who had a cesarean birth with a Foley catheter in place
Rationale: A Foley catheter increases the risk of introducing bacteria into the urinary tract, making UTIs more likely in patients who underwent cesarean birth.
The nurse is teaching a postpartum patient about preventing UTIs. Which statement indicates the need for further teaching?
A. “I should drink plenty of water to flush out bacteria.”
B. “I need to wipe front to back after using the bathroom.”
C. “It’s okay to delay voiding if I’m feeling comfortable.”
D. “Emptying my bladder frequently can help reduce my risk.”
C. “It’s okay to delay voiding if I’m feeling comfortable.”
Rationale: Delaying voiding can lead to urinary stasis, increasing the risk of infection. The nurse should emphasize the importance of regular bladder emptying.
A nurse is caring for a postpartum client whose temperature is 100.6°F (38.1°C) 24 hours after delivery. What is the nurse’s priority action?
A. Offer oral fluids and reassess in one hour.
B. Notify the healthcare provider immediately.
C. Document the finding as normal postpartum recovery.
D. Administer an antipyretic as prescribed.
B. Notify the healthcare provider immediately.
Rationale: A temperature above 100.4°F (38°C) after the first 24 hours postpartum may indicate an infection, requiring prompt reporting and investigation.
A postpartum client asks why her temperature is 100.2°F (37.9°C) a few hours after delivery. What is the nurse’s best response?
A. “This is a sign of an infection; we will need to monitor closely.”
B. “A low-grade fever is a normal immune response after delivery.”
C. “It is likely due to dehydration from fluid loss during labor and will normalize with hydration.”
D. “This is an expected response to uterine involution and does not require monitoring.”
C. “It is likely due to dehydration from fluid loss during labor and will normalize with hydration.”
Rationale: A slight elevation in temperature (up to 100.4°F) during the first 24 hours postpartum is typically due to dehydration from fluid loss during labor and resolves with hydration.
A postpartum client’s temperature is 101.2°F (38.4°C) on the second day postpartum. Which additional finding would most concern the nurse?
A. Profuse sweating overnight
B. Foul-smelling lochia
C. Tender breasts during breastfeeding
D. Mild swelling in the lower extremities
B. Foul-smelling lochia
Rationale: A temperature above 100.4°F postpartum combined with foul-smelling lochia is a strong indicator of infection, such as endometritis, requiring immediate intervention.
The nurse is monitoring the temperature of a postpartum client who had a prolonged labor and rupture of membranes. What action should the nurse prioritize if the client’s temperature rises to 100.8°F (38.2°C) during the first 24 hours postpartum?
A. Encourage the client to drink fluids and reassess the temperature.
B. Document the temperature as normal and continue routine monitoring.
C. Notify the healthcare provider and anticipate a blood culture order.
D. Administer antibiotics as prescribed for presumed sepsis.
C. Notify the healthcare provider and anticipate a blood culture order.
Rationale: An elevated temperature in a client with risk factors such as prolonged labor or rupture of membranes may indicate infection. Reporting the finding and preparing for diagnostic testing is essential.
A nurse is teaching a group of postpartum clients about normal temperature changes. Which statement indicates the need for further teaching?
A. “A temperature up to 100.4°F during the first 24 hours is normal.”
B. “If I have chills and my temperature goes over 100.4°F after 24 hours, I should notify my provider.”
C. “Drinking plenty of fluids can help prevent dehydration-related fever.”
D. “I can expect my temperature to remain slightly elevated for the first 48 hours.”
D. “I can expect my temperature to remain slightly elevated for the first 48 hours.”
Rationale: A temperature elevation should normalize after the first 24 hours postpartum. Persistent elevation beyond this period may indicate infection and requires further evaluation.
The nurse is assessing a postpartum client 12 hours after delivery. The client’s pulse is 65 bpm, and she expresses concern about it being slower than her usual rate. Which response by the nurse is most appropriate?
A. “This is called puerperal bradycardia, which is normal after delivery.”
B. “This could indicate an underlying cardiac issue; I’ll notify the provider.”
C. “Your body is adjusting to fluid loss; we will continue to monitor your vital signs.”
D. “This may indicate exhaustion from labor; I’ll document the finding and check again in an hour.”
A. “This is called puerperal bradycardia, which is normal after delivery.”
Rationale: Puerperal bradycardia (pulse of 60–80 bpm) is a normal finding in the first week postpartum due to increased stroke volume following delivery.
The nurse notes a postpartum client’s pulse rate is 110 bpm 24 hours after delivery. Which of the following findings would most concern the nurse?
A. The client reports feeling anxious and tired.
B. The client’s uterus is firm, and lochia is moderate.
C. The client’s blood pressure is 110/70 mmHg.
D. The client reports dizziness and increased thirst.
D. The client reports dizziness and increased thirst.
Rationale: Tachycardia, along with dizziness and increased thirst, may indicate hypovolemia from excessive blood loss or dehydration, requiring immediate evaluation and intervention.
The nurse is teaching a postpartum client about pulse changes after delivery. Which statement indicates the client understands the teaching?
A. “A slower pulse rate during the first week after birth is expected.”
B. “A pulse rate above 80 bpm is normal after giving birth.”
C. “An increased pulse rate is a normal adjustment to blood volume changes.”
D. “If my pulse is faster than usual, I should drink more fluids and rest.”
A. “A slower pulse rate during the first week after birth is expected.”
Rationale: Puerperal bradycardia, with a resting pulse of 60–80 bpm, is a normal finding postpartum due to increased stroke volume.
Which postpartum client would the nurse prioritize for further evaluation?
A. A client with a pulse of 75 bpm and a blood pressure of 120/80 mmHg
B. A client with a pulse of 65 bpm who reports feeling slightly tired
C. A client with a pulse of 102 bpm and moderate vaginal bleeding
D. A client with a pulse of 60 bpm and no other complaints
C. A client with a pulse of 102 bpm and moderate vaginal bleeding
Rationale: A pulse rate over 100 bpm postpartum may indicate complications such as excessive blood loss or infection and warrants further investigation, especially if accompanied by vaginal bleeding.
The nurse is assessing a postpartum client whose pulse is 105 bpm and temperature is 101.2°F (38.4°C). What is the nurse’s priority action?
A. Encourage the client to rest and recheck vital signs in 1 hour.
B. Document the findings as normal postpartum adjustments.
C. Administer antipyretics as prescribed and monitor the client.
D. Notify the healthcare provider and assess for signs of infection.
D. Notify the healthcare provider and assess for signs of infection.
Rationale: Tachycardia and an elevated temperature postpartum are abnormal and suggest potential infection, such as endometritis or sepsis, requiring immediate reporting and assessment.
Which postpartum client is at highest risk for developing a respiratory complication?
A. A client with a respiratory rate of 16 breaths per minute who had a spontaneous vaginal delivery
B. A client with a history of asthma reporting chest tightness and a respiratory rate of 22 breaths per minute
C. A client with a respiratory rate of 18 breaths per minute and clear lung sounds bilaterally
D. A client who reports feeling fatigued and has a respiratory rate of 14 breaths per minute
B. A client with a history of asthma reporting chest tightness and a respiratory rate of 22 breaths per minute
Rationale: A postpartum client with a history of asthma and an elevated respiratory rate may be at risk for complications such as pulmonary embolism or exacerbation of asthma and should be monitored closely.
The nurse is auscultating the lungs of a postpartum client and notes clear lung sounds bilaterally with a respiratory rate of 18 breaths per minute. What is the most appropriate nursing action?
A. Document the findings as normal.
B. Encourage the client to ambulate to promote pulmonary function.
C. Notify the healthcare provider to report findings.
D. Reassess respiratory status in 15 minutes.
A. Document the findings as normal.
Rationale: A respiratory rate within the normal range (12–20 breaths per minute) and clear lung sounds indicate normal postpartum respiratory function.
The nurse is assessing a postpartum client 6 hours after delivery. The client’s respiratory rate is 10 breaths per minute. Which factor is most likely contributing to this finding?
A. Pulmonary embolism
B. Effects of epidural anesthesia
C. Normal postpartum adaptation
D. Pulmonary edema
B. Effects of epidural anesthesia
Rationale: A respiratory rate below the normal range (12–20 breaths per minute) in a postpartum client may indicate respiratory depression, which can be a side effect of epidural anesthesia.
A postpartum client reports shortness of breath and has a respiratory rate of 26 breaths per minute. What should the nurse do first?
A. Administer oxygen via nasal cannula at 4 L/min.
B. Notify the healthcare provider immediately.
C. Auscultate the lung fields for abnormalities.
D. Reassess the respiratory rate in 30 minutes.
C. Auscultate the lung fields for abnormalities.
Rationale: The nurse should first assess the lung fields to identify any abnormalities, such as crackles or diminished breath sounds, which may help determine if the client is experiencing pulmonary complications.
A postpartum client reports shortness of breath and has a respiratory rate of 26 breaths per 3. During a postpartum assessment, the nurse notes a respiratory rate of 22 breaths per minute and crackles in the lower lobes. Which condition is the nurse most concerned about?
A. Pulmonary embolism
B. Pulmonary edema
C. Atelectasis
D. Normal postpartum respiratory adjustment
B. Pulmonary edema
Rationale: Crackles in the lungs accompanied by an elevated respiratory rate suggest pulmonary edema, which can be a serious postpartum complication.
A postpartum client with an epidural reports feeling lightheaded and faint. Her blood pressure is 88/60 mm Hg. What is the most appropriate nursing action?
A. Place the client in a supine position with her legs elevated.
B. Encourage oral hydration and continue to monitor.
C. Reassess the blood pressure in 30 minutes.
D. Notify the healthcare provider and prepare for a blood transfusion.
A. Place the client in a supine position with her legs elevated.
Rationale: The client is likely experiencing hypotension due to epidural anesthesia. Placing her in a supine position with legs elevated promotes venous return and stabilizes blood pressure.
The nurse assesses a postpartum client and notes a blood pressure reading of 82/58 mm Hg. Which additional findings would indicate hypovolemic shock?
A. Clear lung sounds and a heart rate of 75 bpm
B. Increased respiratory rate and cool, clammy skin
C. Bounding pulse and facial flushing
D. Warm extremities and mild dizziness
B. Increased respiratory rate and cool, clammy skin
Rationale: Hypovolemic shock is characterized by hypotension, increased respiratory rate, and signs of poor perfusion such as cool, clammy skin.
A postpartum client complains of dizziness when moving from a lying to a standing position. Her blood pressure drops from 120/80 mm Hg to 88/62 mm Hg. What is the nurse’s priority intervention?
A. Encourage the client to ambulate frequently to improve circulation.
B. Administer IV fluids to address dehydration.
C. Advise the client to rise slowly and assist her as needed.
D. Notify the healthcare provider immediately.
C. Advise the client to rise slowly and assist her as needed.
Rationale: Orthostatic hypotension can occur postpartum. The priority intervention is to advise the client to rise slowly and provide assistance to prevent falls or injury.
The nurse is preparing to assess the blood pressure of a postpartum client. Which action ensures the most accurate reading?
A. Measure the blood pressure in both arms and document the average.
B. Use a manual cuff and take the measurement while the client is standing.
C. Take the blood pressure with the client in the same position as previous assessments.
D. Measure the blood pressure after the client has ambulated for 10 minutes.
C. Take the blood pressure with the client in the same position as previous assessments.
Rationale: Blood pressure can vary based on positioning; assessing it in the same position each time ensures consistency and accuracy in identifying trends or abnormalities.
A postpartum client has a blood pressure reading of 146/92 mm Hg. Which condition should the nurse suspect?
A. Orthostatic hypotension
B. Dehydration
C. Hypovolemic shock
D. Gestational hypertension
D. Gestational hypertension
Rationale: A blood pressure reading above 140/90 mm Hg postpartum may indicate gestational hypertension. This finding should be monitored and reported to the healthcare provider.
The nurse assesses a postpartum client who rates her pain as 6/10. The client’s perineum appears swollen with no visible hematoma. What intervention should the nurse implement first?
A. Apply an ice pack to the perineal area.
B. Administer prescribed analgesics.
C. Elevate the client’s legs to reduce swelling.
D. Notify the healthcare provider immediately.
A. Apply an ice pack to the perineal area.
Rationale: Applying an ice pack is the first-line intervention for swelling and pain in the perineal area, as it reduces inflammation and provides comfort.
A postpartum client expresses anxiety about her pain level increasing during routine assessments. What should the nurse prioritize?
A. Provide routine analgesics before assessments.
B. Perform all assessments at once to minimize disruptions.
C. Explain the purpose of assessments to the client.
D. Reassure the client that the pain will subside soon.
A. Provide routine analgesics before assessments.
Rationale: Preventing pain through routine analgesics is a key strategy in postpartum care, ensuring the client remains comfortable during assessments.
The nurse provides comfort measures for a postpartum client experiencing perineal pain. Which action is most effective in promoting pain relief?
A. Offering oral hydration frequently.
B. Repositioning the client frequently.
C. Applying warm blankets to the lower abdomen.
D. Performing perineal care and ensuring cleanliness.
B. Repositioning the client frequently.
Rationale: Perineal care helps reduce discomfort by maintaining cleanliness, preventing infection, and promoting healing in the affected area.
During a postpartum assessment, a client rates her pain as 4/10 and requests pain medication. The nurse observes the client moving comfortably in bed. What should the nurse do next?
A. Administer the prescribed analgesic as requested.
B. Reassess the pain level in 15 minutes.
C. Encourage nonpharmacological pain relief measures first.
D. Document the observation and withhold the analgesic.
A. Administer the prescribed analgesic as requested.
Rationale: Pain is subjective, and the nurse should believe the client’s self-report. Administering the prescribed analgesic ensures comfort and supports healing.
A nurse is providing education on managing afterbirth pains. Which recommendation is most effective for minimizing pain after breastfeeding?
A. Encourage walking immediately after breastfeeding.
B. Administer prescribed analgesics before breastfeeding.
C. Apply warm compresses to the perineum after breastfeeding.
D. Perform perineal massage before breastfeeding.
B. Administer prescribed analgesics before breastfeeding.
Rationale: Afterbirth pains often intensify after breastfeeding due to uterine contractions. Administering analgesics beforehand helps manage this pain effectively.
A postpartum client reports perineal pain rated at 8/10 despite routine analgesic administration and physical comfort measures. What is the nurse’s priority action?
A. Administer an additional dose of pain medication.
B. Inspect and palpate the perineal area for a hematoma.
C. Encourage the client to perform deep breathing exercises.
D. Reassess the pain level in 30 minutes.
B. Inspect and palpate the perineal area for a hematoma.
Rationale: Severe perineal pain that does not respond to routine measures may indicate a hematoma. The nurse should assess for this and notify the healthcare provider if one is found.
The nurse is educating a postpartum client about signs of infection. Which statement indicates the client understands the teaching?
A. “If I have bright red bleeding, I should notify my doctor immediately.”
B. “I should monitor my heart rate for signs of an infection.”
C. “Swelling in my legs is the first sign of an infection.”
D. “A temperature of 100.5°F or higher could mean I have an infection.”
D. “A temperature of 100.5°F or higher could mean I have an infection.”
Rationale: A postpartum temperature higher than 100.4°F (38°C) is a potential sign of infection and requires prompt reporting and evaluation.
A postpartum client with twins is being assessed. What complication is she at greatest risk for?
A. Postpartum infection
B. Postpartum hemorrhage
C. Thromboembolism
D. Breastfeeding difficulties
B. Postpartum hemorrhage
Rationale: Uterine overdistention from a twin pregnancy increases the risk of uterine atony, which can lead to postpartum hemorrhage.
Which intervention is most important for a postpartum client with a history of manual extraction of the placenta?
A. Encourage early ambulation to prevent thromboembolism.
B. Monitor closely for signs of retained placental fragments.
C. Administer iron supplements to prevent anemia.
D. Teach perineal hygiene to reduce infection risk.
B. Monitor closely for signs of retained placental fragments.
Rationale: Manual extraction of the placenta increases the risk of retained fragments, which can lead to hemorrhage or infection.
A postpartum client had a prolonged labor with an indwelling urinary catheter and multiple vaginal examinations. Which complication is the nurse most concerned about?
A. Postpartum hemorrhage
B. Postpartum infection
C. Thromboembolic disorder
D. Postpartum depression
B. Postpartum infection
Rationale: Prolonged labor, use of an indwelling urinary catheter, and multiple vaginal examinations are significant risk factors for postpartum infection.
A postpartum client presents with uterine atony and a history of placenta previa. What is the priority nursing intervention?
A. Encourage ambulation to promote uterine contraction.
B. Administer oxytocin as prescribed.
C. Monitor intake and output.
D. Prepare the client for a blood transfusion.
B. Administer oxytocin as prescribed.
Rationale: Uterine atony is the leading cause of postpartum hemorrhage, and administering oxytocin helps stimulate uterine contractions to control bleeding.
Which client is at greatest risk for postpartum hemorrhage?
A. A client with anemia and a history of gestational diabetes
B. A client who delivered vaginally after a 10-hour labor
C. A client who had manual extraction of the placenta
D. A client with hydramnios and a prolonged third stage of labor
D. A client with hydramnios and a prolonged third stage of labor
Rationale: Hydramnios and a prolonged third stage of labor increase the risk of uterine overdistention and retained placental fragments, leading to postpartum hemorrhage.
During assessment, the nurse notes that a postpartum client has a hemoglobin level of 10.2 mg/dL. Which postpartum complication is this client most at risk for?
A. Postpartum hemorrhage
B. Postpartum depression
C. Postpartum infection
D. Delayed milk production
C. Postpartum infection
Rationale: Anemia (hemoglobin <10.5 mg/dL) increases the risk of postpartum infection due to reduced immune function and impaired healing.
A postpartum client with a cesarean birth and retained placental fragments is being monitored closely. Which assessment finding requires immediate action?
A. Vaginal bleeding saturating a pad in 2 hours
B. Temperature of 100.3°F (37.9°C)
C. Uterine tenderness with foul-smelling lochia
D. Slight edema of the lower extremities
C. Uterine tenderness with foul-smelling lochia
Rationale: Uterine tenderness with foul-smelling lochia suggests infection, which is a serious postpartum complication requiring prompt intervention.
The nurse is caring for a postpartum client who had a precipitous labor. What is the nurse’s priority assessment?
A. Assessing for uterine atony and hemorrhage
B. Monitoring for signs of infection
C. Checking for signs of thromboembolism
D. Evaluating for bonding issues
A. Assessing for uterine atony and hemorrhage
Rationale: Precipitous labor increases the risk of uterine atony and postpartum hemorrhage due to the rapid delivery and potential trauma to uterine muscles.
A client had a prolonged rupture of membranes and is now 12 hours postpartum. What is the priority nursing action?
A. Assess the client’s respiratory rate and oxygen saturation.
B. Monitor the client’s temperature and lochia characteristics.
C. Palpate the client’s uterus for firmness and position.
D. Encourage the client to ambulate frequently.
B. Monitor the client’s temperature and lochia characteristics.
Rationale: Prolonged rupture of membranes increases the risk of infection; monitoring temperature and lochia can help identify early signs of endometritis.
Which intervention is most important for a postpartum client with a history of manual extraction of the placenta?
A. Encourage early ambulation to prevent thromboembolism.
B. Monitor closely for signs of retained placental fragments.
C. Administer iron supplements to prevent anemia.
D. Teach perineal hygiene to reduce infection risk.
B. Monitor closely for signs of retained placental fragments.
Rationale: Manual extraction of the placenta increases the risk of retained fragments, which can lead to hemorrhage or infection.
A postpartum client with twins is being assessed. What complication is she at greatest risk for?
A. Postpartum hemorrhage
B. Postpartum infection
C. Thromboembolism
D. Breastfeeding difficulties
A. Postpartum hemorrhage
Rationale: Uterine overdistention from a twin pregnancy increases the risk of uterine atony, which can lead to postpartum hemorrhage.
The nurse is educating a postpartum client about signs of infection. Which statement indicates the client understands the teaching?
A. “If I have bright red bleeding, I should notify my doctor immediately.”
B. “A temperature of 100.5°F or higher could mean I have an infection.”
C. “I should monitor my heart rate for signs of an infection.”
D. “Swelling in my legs is the first sign of an infection.”
B. “A temperature of 100.5°F or higher could mean I have an infection.”
Rationale: A postpartum temperature higher than 100.4°F (38°C) is a potential sign of infection and requires prompt reporting and evaluation.
A postpartum client had a prolonged labor with an indwelling urinary catheter and multiple vaginal examinations. Which complication is the nurse most concerned about?
A. Postpartum infection
B. Postpartum hemorrhage
C. Thromboembolic disorder
D. Postpartum depression
A. Postpartum infection
Rationale: Prolonged labor, use of an indwelling urinary catheter, and multiple vaginal examinations are significant risk factors for postpartum infection.
A postpartum client presents with uterine atony and a history of placenta previa. What is the priority nursing intervention?
A. Encourage ambulation to promote uterine contraction.
B. Administer oxytocin as prescribed.
C. Monitor intake and output.
D. Prepare the client for a blood transfusion.
B. Administer oxytocin as prescribed.
Rationale: Uterine atony is the leading cause of postpartum hemorrhage, and administering oxytocin helps stimulate uterine contractions to control bleeding.
Which client is at greatest risk for postpartum hemorrhage?
A. A client with hydramnios and a prolonged third stage of labor
B. A client with anemia and a history of gestational diabetes
C. A client who delivered vaginally after a 10-hour labor
D. A client who had manual extraction of the placenta
A. A client with hydramnios and a prolonged third stage of labor
Rationale: Hydramnios and a prolonged third stage of labor increase the risk of uterine overdistention and retained placental fragments, leading to postpartum hemorrhage.
During assessment, the nurse notes that a postpartum client has a hemoglobin level of 10.2 mg/dL. Which postpartum complication is this client most at risk for?
A. Postpartum hemorrhage
B. Postpartum depression
C. Postpartum infection
D. Delayed milk production
C. Postpartum infection
Rationale: Anemia (hemoglobin <10.5 mg/dL) increases the risk of postpartum infection due to reduced immune function and impaired healing.
A postpartum client with a cesarean birth and retained placental fragments is being monitored closely. Which assessment finding requires immediate action?
A. Vaginal bleeding saturating a pad in 2 hours
B. Temperature of 100.3°F (37.9°C)
C. Uterine tenderness with foul-smelling lochia
D. Slight edema of the lower extremities
C. Uterine tenderness with foul-smelling lochia
Rationale: Uterine tenderness with foul-smelling lochia suggests infection, which is a serious postpartum complication requiring prompt intervention.
The nurse is caring for a postpartum client who had a precipitous labor. What is the nurse’s priority assessment?
A. Assessing for uterine atony and hemorrhage
B. Monitoring for signs of infectio
C. Checking for signs of thromboembolism
D. Evaluating for bonding issues
A. Assessing for uterine atony and hemorrhage
Rationale: Precipitous labor increases the risk of uterine atony and postpartum hemorrhage due to the rapid delivery and potential trauma to uterine muscles.
A client had a prolonged rupture of membranes and is now 12 hours postpartum. What is the priority nursing action?
A. Assess the client’s respiratory rate and oxygen saturation.
B. Palpate the client’s uterus for firmness and position.
C. Encourage the client to ambulate frequently.
D. Monitor the client’s temperature and lochia characteristics.
D. Monitor the client’s temperature and lochia characteristics.
Rationale: Prolonged rupture of membranes increases the risk of infection; monitoring temperature and lochia can help identify early signs of endometritis.
The nurse is assessing a postpartum client who reports shortness of breath without exertion. What is the nurse’s priority intervention?
A. Elevate the head of the bed and provide oxygen as needed
B. Assess for signs of pulmonary edema or embolism
C. Encourage deep breathing exercises and coughing
D. Notify the healthcare provider and prepare for a chest X-ray
B. Assess for signs of pulmonary edema or embolism
Rationale: Shortness of breath without exertion is a potential sign of pulmonary embolism or edema, both of which are life-threatening conditions requiring immediate assessment and intervention.
A postpartum client reports foul-smelling lochia. Which condition is most likely causing this finding?
A. Endometritis
B. Subinvolution of the uterus
C. Vaginal infection
D. Retained placental fragments
A. Endometritis
Rationale: Foul-smelling lochia is a classic symptom of endometritis, a postpartum uterine infection that requires prompt treatment with antibiotics.
The nurse is assessing a postpartum client and notes calf pain with dorsiflexion of the foot. What is the nurse’s priority action?
A. Apply a warm compress to the affected area
B. Encourage the client to ambulate to improve circulation
C. Perform a full musculoskeletal assessment
D. Notify the healthcare provider immediately
D. Notify the healthcare provider immediately
Rationale: Calf pain with dorsiflexion (positive Homan’s sign) suggests a possible deep vein thrombosis (DVT), a serious condition that requires immediate medical attention.
Which assessment finding in a postpartum client requires immediate intervention?
A. Lochia rubra with small clots on day 2 postpartum
B. Saturation of a peripad within 1 hour
C. Low-grade fever of 100.2°F (37.9°C)
D. Mild swelling around the episiotomy site
B. Saturation of a peripad within 1 hour
Rationale: Saturating a peripad within an hour indicates heavy bleeding, a potential sign of postpartum hemorrhage that requires immediate intervention.
The nurse is assessing a postpartum client who reports dysuria and a burning sensation during urination. What is the most likely cause of these symptoms?
A. Dehydration from fluid loss during labor
B. Vaginal laceration
C. Urinary tract infection (UTI)
D. Bladder distention
C. Urinary tract infection (UTI)
Rationale: Dysuria and burning are classic signs of a UTI, which is a common postpartum complication due to catheter use or trauma during delivery.
A postpartum client reports a severe headache and blurred vision. What is the nurse’s priority intervention?
A. Administer acetaminophen and reassess in 1 hour
B. Perform a neurological assessment and monitor blood pressure
C. Encourage fluid intake to prevent dehydration
D. Notify the healthcare provider and prepare for magnesium sulfate administration
B. Perform a neurological assessment and monitor blood pressure
Rationale: Severe headache and blurred vision are potential signs of preeclampsia, requiring a neurological assessment and blood pressure monitoring to identify hypertensive complications.
What is the primary component of lochia rubra during the first three days postpartum?
A. Old blood, leukocytes, and debris
B. Blood and decidual and trophoblastic debris
C. Leukocytes, mucus, and epithelial cells
D. Serum and bacteria
B. Blood and decidual and trophoblastic debris
Rationale: Lochia rubra primarily contains blood, decidual, and trophoblastic debris. This stage typically lasts for the first three days postpartum.
During an assessment of a postpartum client on day 5, the nurse notes the vaginal discharge is red with a yellow tinge. How should the nurse document this finding?
A. Lochia rubra
B. Lochia serosa
C. Lochia alba
D. Abnormal lochia
B. Lochia serosa
Rationale: Lochia serosa occurs from days 4 through 10 postpartum and is characterized by old blood, serum, leukocytes, and debris, which can give the discharge a red to yellow tinge.
A nurse is teaching a postpartum client about lochia. Which statement by the client indicates the need for further teaching?
A. “Lochia rubra lasts for about three days.”
B. “I should notify my nurse if the discharge has a foul odor.”
C. “A heavy flow of lochia rubra after resting may be normal.”
D. “Lochia alba should stop by the end of the second week.”
D. “Lochia alba should stop by the end of the second week.”
Rationale: Lochia alba typically lasts beyond the second week and can persist for several weeks. The other statements reflect correct understanding.
What is the most appropriate action if a nurse notes a heavy flow of lochia rubra accompanied by a boggy uterus?
A. Notify the healthcare provider immediately.
B. Administer prescribed antibiotics.
C. Perform fundal massage to firm the uterus.
D. Reassess the client’s lochia in one hour.
C. Perform fundal massage to firm the uterus.
Rationale: A boggy uterus indicates uterine atony, which can lead to excessive lochia rubra. The priority is to perform a fundal massage to promote uterine contraction and reduce bleeding.
The nurse is assessing a postpartum client’s vital signs. Which findings may indicate significant blood loss from excessive lochia? (SATA)
A. Tachycardia
B. Hypotension
C. Hypertension
D. Tachypnea
E. Decreased oxygen saturation
A. Tachycardia
B. Hypotension
D. Tachypnea
Rationale: Significant blood loss (30–40% of total blood volume) can lead to tachycardia, hypotension, and tachypnea as compensatory mechanisms for hypovolemia. Hypertension and decreased oxygen saturation are not typical early findings in postpartum hemorrhage.
A postpartum client is concerned about foul-smelling lochia. The nurse knows this could indicate:
A. Normal postpartum healing.
B. Retained placental fragments.
C. Uterine infection.
D. Overdistension of the uterus.
C. Uterine infection.
Rationale: Foul-smelling lochia is often a sign of uterine infection (endometritis). Retained placental fragments and uterine overdistension can contribute to infection, but the primary concern is the infection itself.
A nurse is monitoring a postpartum client’s lochia and notes a transition from lochia serosa to lochia rubra on day 8. What is the nurse’s best action?
A. Document the findings as normal.
B. Encourage the client to increase ambulation.
C. Notify the healthcare provider.
D. Instruct the client to avoid breastfeeding.
C. Notify the healthcare provider.
Rationale: Lochia transitioning back to rubra (from serosa or alba) after day 4–5 postpartum may indicate subinvolution or infection, requiring prompt evaluation and intervention.
A postpartum client asks the nurse how long she will experience vaginal discharge. Which response is most accurate?
A. “Lochia typically stops after the first week postpartum.”
B. “Lochia may continue for 4 to 8 weeks postpartum.”
C. “Lochia is completely gone by the third week postpartum.”
D. “The duration of lochia depends entirely on the mode of delivery.”
B. “Lochia may continue for 4 to 8 weeks postpartum.”
Rationale: Lochia can persist for 4 to 8 weeks postpartum as the endometrium undergoes restoration. While cesarean births tend to have less lochia due to manual debris removal, duration is not solely dependent on delivery mode.
During a postpartum assessment, the nurse notes lochia serosa on day 12. How should the nurse interpret this finding?
A. Normal for this stage of postpartum recovery
B. Indicative of endometritis
C. Suggestive of delayed involution
D. A normal variant if no other symptoms are present
C. Suggestive of delayed involution
Rationale: Lochia serosa typically transitions to lochia alba by day 10. Persistence of serosa beyond this time may indicate delayed involution, requiring further evaluation.
What is the normal composition of lochia alba?
A. Leukocytes, decidual tissue, and reduced fluid content
B. Blood, fibrinous products, decidual cells, and leukocytes
C. Red blood cells, serous fluid, and decidual tissue
D. Mucus, tissue debris, and red blood cells
A. Leukocytes, decidual tissue, and reduced fluid content
Rationale: Lochia alba, the final stage of lochia, is characterized by leukocytes, decidual tissue, and reduced fluid content. It is creamy white or light brown in color.
The nurse is teaching a postpartum client about signs of abnormal lochia. Which findings should the client report to her healthcare provider? (SATA)
A. Lochia with an offensive odor
B. Bright red lochia on day 15
C. Creamy white lochia on day 11
D. Lochia transitioning from alba back to rubra
E. Heavy flow with large clots
A. Lochia with an offensive odor
B. Bright red lochia on day 15
D. Lochia transitioning from alba back to rubra
E. Heavy flow with large clots
Rationale: Lochia with a foul odor indicates infection. Bright red lochia or a transition back to rubra after day 4–10 may indicate subinvolution or infection. Heavy flow with large clots is also abnormal. Creamy white lochia on day 11 is normal for lochia alba.
A postpartum client reports lochia with a fleshy odor. How should the nurse respond?
A. “This is a normal finding during the postpartum period.”
B. “I will notify the healthcare provider of your symptoms.”
C. “This could indicate retained placental fragments.”
D. “You may need a pelvic exam to confirm infection.”
A. “This is a normal finding during the postpartum period.”
Rationale: Lochia at any stage should have a fleshy odor. An offensive or foul odor, however, is not normal and should be reported.
A nurse is assessing the lochia of a client 5 days postpartum. What characteristics should the nurse expect to find?
A. Deep red lochia with a fleshy odor
B. Pinkish brown lochia with leukocytes and serous fluid
C. Creamy white lochia with reduced fluid content
D. Minimal lochia with no color
B. Pinkish brown lochia with leukocytes and serous fluid
Rationale: By day 5 postpartum, the lochia is typically in the serosa stage, characterized by a pinkish-brown color with leukocytes, decidual tissue, red blood cells, and serous fluid.
Which postpartum factor is most likely to reduce the amount of lochia in a client?
A. Vaginal delivery
B. Breastfeeding
C. Anemia during pregnancy
D. Cesarean birth
D. Cesarean birth
Rationale: Cesarean births tend to result in less lochia because uterine debris is manually removed during surgery, reducing the amount of discharge postpartum.
Which statement by a postpartum client indicates a need for further teaching about breast care?
A. “I will wear a snug, supportive bra even when I’m sleeping.”
B. “I will avoid using soap on my nipples to prevent drying.”
C. “If I feel engorged, I’ll apply warm compresses to relieve discomfort.”
D. “I’ll use scented lotions to keep my nipples moisturized.”
D. “I’ll use scented lotions to keep my nipples moisturized.”
Rationale: Scented lotions can cause irritation and are not recommended for breast care. Moisturization should be done using natural methods like lanolin cream or expressed breast milk.
What instruction should the nurse give to a postpartum client experiencing nipple dryness and cracking?
A. “Clean your nipples with soap and water after each feeding.”
B. “Avoid wearing a bra to allow the nipples to heal.”
C. “Use alcohol-based wipes to disinfect the area.”
D. “Apply a lanolin-based cream or breast milk to the nipples after feeding.”
D. “Apply a lanolin-based cream or breast milk to the nipples after feeding.”
Rationale: Lanolin cream or breast milk can soothe and promote healing of cracked nipples. Soap, alcohol, or avoiding a bra may exacerbate the problem.
A postpartum client who is not breastfeeding asks how to reduce breast engorgement. What teaching should the nurse provide?
A. “Wear a snug, supportive bra continuously until the engorgement resolves.”
B. “Apply warm compresses to the breasts and express milk as needed.”
C. “Massage the breasts frequently to decrease swelling.”
D. “Use breast binders and avoid wearing a bra.”
A. “Wear a snug, supportive bra continuously until the engorgement resolves.”
Rationale: A snug, supportive bra helps alleviate discomfort and promote resolution of engorgement. Warm compresses and expressing milk are only recommended for breastfeeding mothers.
A postpartum client who is breastfeeding asks about proper breast hygiene. What is the most appropriate response by the nurse?
A. “Clean your breasts daily with soap and water.”
B. “Use plain water to clean your breasts, avoiding soap on the nipples.”
C. “Apply lanolin ointment after every feeding to prevent dryness.”
D. “Avoid washing your breasts frequently to retain natural oils.”
B. “Use plain water to clean your breasts, avoiding soap on the nipples.”
Rationale: Plain water is recommended for breast hygiene as soap can dry the nipples and lead to cracking, increasing the risk of infection.
The nurse is teaching a breastfeeding mother how to assess her breasts. Which statement by the client indicates understanding of the teaching?
A. “I will check for signs of redness, bruising, or bleeding on my nipples daily.”
B. “If my breasts are engorged, I will wait 24 hours before feeding my baby.”
C. “I will avoid touching my nipples to prevent irritation.”
D. “If my breasts feel soft, it means I need to feed my baby less frequently.”
A. “I will check for signs of redness, bruising, or bleeding on my nipples daily.”
Rationale: Monitoring for nipple changes such as redness, bruising, or bleeding is crucial to identify potential issues early. Avoiding feeding or touching nipples can exacerbate problems. Soft breasts may indicate adequate milk removal, not the need to reduce feeding frequency.
Which finding during a breast assessment of a nonlactating postpartum client would require immediate intervention?
A. Breasts are soft and non-tender.
B. A red, warm area is present on one breast.
C. Breasts are firm and slightly engorged.
D. Nipples are flat but intact.
B. A red, warm area is present on one breast.
Rationale: A red, warm area on the breast could indicate mastitis, which requires prompt intervention to prevent complications.
A breastfeeding mother reports cracked and bleeding nipples. What should the nurse include in the teaching plan?
A. Limit breastfeeding to every 6 hours to allow the nipples to heal.
B. Apply lanolin cream or expressed breast milk to the nipples after each feeding.
C. Use soap and water to clean the nipples after every breastfeeding session.
D. Pump breast milk and feed it to the baby with a bottle until the nipples heal.
B. Apply lanolin cream or expressed breast milk to the nipples after each feeding.
Rationale: Lanolin cream or expressed breast milk can promote healing and protect the nipples. Soap and water can cause further dryness and irritation.
During a postpartum assessment, a nurse observes that the client’s breasts are firm and engorged. What is the most appropriate nursing intervention?
A. Encourage the client to apply cold compresses between feedings.
B. Advise the client to avoid breastfeeding until the engorgement resolves.
C. Instruct the client to massage the breasts and apply warm compresses.
D. Suggest wearing a loose-fitting bra to relieve pressure.
A. Encourage the client to apply cold compresses between feedings.
Rationale: Cold compresses between feedings help reduce swelling and relieve discomfort caused by engorgement. Warm compresses and massage are only appropriate just before feeding to assist with milk let-down.
Which finding during a breast assessment of a nonlactating postpartum client would require immediate intervention?
A. Breasts are soft and non-tender.
B. A red, warm area is present on one breast.
C. Breasts are firm and slightly engorged.
D. Nipples are flat but intact.
B. A red, warm area is present on one breast.
Rationale: A red, warm area on the breast could indicate mastitis, which requires prompt intervention to prevent complications.
The nurse is teaching a breastfeeding mother how to assess her breasts. Which statement by the client indicates understanding of the teaching?
A. “I will check for signs of redness, bruising, or bleeding on my nipples daily.”
B. “If my breasts are engorged, I will wait 24 hours before feeding my baby.”
C. “I will avoid touching my nipples to prevent irritation.”
D. “If my breasts feel soft, it means I need to feed my baby less frequently.”
A. “I will check for signs of redness, bruising, or bleeding on my nipples daily.”
Rationale: Monitoring for nipple changes such as redness, bruising, or bleeding is crucial to identify potential issues early. Avoiding feeding or touching nipples can exacerbate problems. Soft breasts may indicate adequate milk removal, not the need to reduce feeding frequency.
A postpartum woman wishes to suppress lactation. Which of the following should the nurse recommend to decrease breast discomfort?
A. Avoid drinking fluids to reduce milk production.
B. Bind the breasts tightly with a compression bandage.
C. Allow warm shower water to flow over the breasts.
D. Use ice packs or cool compresses and change them every 30 minutes.
D. Use ice packs or cool compresses and change them every 30 minutes.
Rationale: Ice packs or cool compresses help reduce local pain and swelling. Warm water or breast binding can stimulate milk production or cause discomfort.
What should the nurse include in teaching a postpartum woman about fluid intake while suppressing lactation?
A. Restrict fluid intake to dry up milk production.
B. Drink only small amounts of water to reduce milk supply.
C. Drink to quench thirst without restricting fluid intake.
D. Increase salt intake to decrease milk production.
C. Drink to quench thirst without restricting fluid intake.
Rationale: Restricting fluids does not help dry up milk; drinking enough to quench thirst is recommended to stay hydrated.
Which teaching point is appropriate for a postpartum woman who wishes to suppress lactation?
A. Massage the breasts to relieve discomfort.
B. Wear a loose-fitting bra to prevent swelling.
C. Apply warm compresses to ease engorgement.
D. Take mild analgesics to reduce breast pain.
D. Take mild analgesics to reduce breast pain.
Rationale: Mild analgesics are appropriate for reducing breast discomfort. Breast massage, loose-fitting bras, and warm compresses may stimulate milk production.
A mother is suppressing lactation and complains of swollen, painful breasts. What is the nurse’s best recommendation?
A. Pump the breasts to remove milk and reduce discomfort.
B. Allow her infant to latch briefly to relieve pressure.
C. Use ice packs or cool compresses to decrease pain and swelling.
D. Increase salt intake to decrease fluid retention in the breasts.
C. Use ice packs or cool compresses to decrease pain and swelling.
Rationale: Cool compresses help decrease swelling and pain without stimulating milk production. Pumping, latching, and increased salt intake are inappropriate.
Which statement by a postpartum woman indicates a need for further teaching about lactation suppression?
A. “I will wear a snugly fitting bra 24 hours a day.”
B. “I should let warm water from the shower flow over my breasts to relieve pain.”
C. “I can take mild analgesics to help with breast discomfort.”
D. “I will use ice packs to reduce pain and swelling in my breasts.”
B. “I should let warm water from the shower flow over my breasts to relieve pain.”
Rationale: Warm water flowing over the breasts can stimulate milk production and should be avoided; cool compresses are recommended instead.
How long does the nurse advise a postpartum woman it may take to fully suppress lactation?
A. 2 to 3 days
B. 3 to 4 days
C. 5 to 7 days
D. 8 to 10 days
C. 5 to 7 days
Rationale: Lactation suppression typically takes 5 to 7 days, and the mother should follow the recommended guidelines during this period.
Which recommendation would help reduce fluid retention for a postpartum woman suppressing lactation?
A. Increase fluid intake.
B. Decrease salt intake.
C. Use warm compresses.
D. Massage the breasts daily.
B. Decrease salt intake.
Rationale: Reducing salt intake can help decrease fluid retention, minimizing swelling and discomfort during lactation suppression.
A postpartum woman asks why she should avoid breast stimulation while suppressing lactation. What is the nurse’s best response?
A. “Stimulation increases milk production and delays lactation suppression.”
B. “Stimulation could lead to mastitis if milk is not expressed.”
C. “It causes milk to dry up too quickly, leading to discomfort.”
D. “Breast stimulation has no effect on the suppression process.”
A. “Stimulation increases milk production and delays lactation suppression.”
Rationale: Any breast stimulation, such as massage or sucking, increases milk production, which can prolong the lactation suppression process.
A client presents with redness and tenderness in the upper outer quadrant of her breast. She is diagnosed with mastitis. Which area should the nurse explain is most commonly affected by mastitis?
A. Lower inner quadrant
B. Areola and nipple region
C. Central breast tissue near the chest wall
D. Upper outer quadrant
D. Upper outer quadrant
Rationale: The upper outer quadrant of the breast is the most common site for mastitis due to the larger amount of breast tissue in this area.
The nurse is teaching a postpartum client with mastitis about the condition. Which statement indicates the client needs further teaching?
A. “I will continue to breast-feed even with mastitis.”
B. “I can alternate warm compresses and effective milk removal.”
C. “I should wean my baby immediately to help my breast heal.”
D. “I will contact my provider if I experience flu-like symptoms.”
C. “I should wean my baby immediately to help my breast heal.”
Rationale: Weaning is not typically recommended with mastitis unless advised by a healthcare provider, as milk stasis may worsen the condition.
What should the nurse include when teaching a postpartum woman about signs of mastitis?
A. Swollen lymph nodes in the axillary area
B. Fever and localized breast tenderness
C. Burning sensation while urinating
D. Severe headaches and visual disturbances
B. Fever and localized breast tenderness
Rationale: Fever, localized tenderness, and redness are hallmark signs of mastitis. The condition does not typically involve urinary symptoms or headaches.
Which factor is most likely to contribute to the development of mastitis in a lactating woman?
A. Wearing a loose-fitting bra
B. Breast-feeding on both sides at each feeding
C. Pressure on the breast from a poorly fitting bra
D. Taking analgesics without addressing breast discomfort
C. Pressure on the breast from a poorly fitting bra
Rationale: A poorly fitting bra that exerts pressure on the breast can cause milk stasis, increasing the risk of mastitis.
The nurse is caring for a postpartum client with mastitis. Which clinical findings are most consistent with this condition?
A. Breast tenderness, redness, and flu-like symptoms
B. Swelling, warmth, and a firm lump in the breast
C. Itchy, flaky skin and inverted nipples
D. Painful breast engorgement with no systemic symptoms
A. Breast tenderness, redness, and flu-like symptoms
Rationale: Mastitis presents with flu-like symptoms, redness, tenderness, and heat in the affected breast.
A postpartum woman is diagnosed with mastitis. Which nursing intervention is appropriate to include in the care plan?
A. Encourage effective milk removal and administer prescribed antibiotics.
B. Advise the client to stop breast-feeding from the affected breast.
C. Suggest rapid weaning to allow the breast to heal.
D. Apply cold compresses to the affected area to reduce inflammation.
A. Encourage effective milk removal and administer prescribed antibiotics.
Rationale: Effective milk removal and antibiotic therapy are critical components of mastitis treatment. Breast-feeding should continue unless contraindicated.
The nurse is teaching a postpartum client about preventing mastitis. Which recommendation should be included?
A. Avoid nursing if the nipples are cracked or fissured.
B. Ensure frequent and consistent breast-feeding sessions.
C. Limit breast-feeding to one breast per feeding.
D. Use a snugly fitting, supportive bra to suppress lactation.
B. Ensure frequent and consistent breast-feeding sessions.
Rationale: Frequent, consistent feeding prevents milk stasis, a major risk factor for mastitis. Cracked nipples should be treated, but breast-feeding is still encouraged with proper care.
What is the most common causative organism for lactational mastitis?
A. Escherichia coli
B. Staphylococcus aureus
C. Streptococcus pyogenes
D. Staphylococcus albus
B. Staphylococcus aureus
Rationale: Staphylococcus aureus is the most common organism responsible for lactational mastitis, often originating from the infant’s mouth or throat.
Which client behavior places a postpartum woman at increased risk for developing mastitis?
A. Breast-feeding every 2 to 3 hours consistently
B. Wearing a properly fitting bra without pressure on the breasts
C. Frequently skipping breast-feeding sessions
D. Using manual expression after feeding
C. Frequently skipping breast-feeding sessions
Rationale: Infrequent or skipped feedings lead to milk stasis, a significant risk factor for mastitis. Consistent feeding and milk drainage reduce this risk.
A postpartum client reports flu-like symptoms and redness in the upper, outer quadrant of her right breast. Which of the following actions should the nurse prioritize?
A. Encourage the client to stop breast-feeding immediately.
B. Advise warm compresses and rest, and monitor for changes.
C. Notify the healthcare provider for potential antibiotic therapy.
D. Instruct the client to switch to formula feeding permanently.
C. Notify the healthcare provider for potential antibiotic therapy.
Rationale: Mastitis often requires antibiotic therapy, effective milk removal, and pain management. Stopping breast-feeding is not recommended unless otherwise advised.
Which intervention should the nurse prioritize when providing education to a postpartum client about managing mastitis?
A. Administer antibiotics only if the fever persists for more than 72 hours.
B. Reassure the client that continuing breast-feeding is safe and beneficial.
C. Recommend abrupt weaning to prevent further complications.
D. Advise restricting fluids to reduce milk production.
B. Reassure the client that continuing breast-feeding is safe and beneficial.
Rationale: Continuing breast-feeding helps manage mastitis by promoting milk removal and is safe for both the mother and infant. Antibiotics should be started as prescribed, and abrupt weaning or fluid restriction is not recommended.
Which nursing action is most appropriate for a postpartum client with mastitis who reports pain and tenderness?
A. Encourage warm compresses before feedings to promote milk flow.
B. Recommend tight bras to provide breast support.
C. Advise decreasing feeding frequency to reduce discomfort.
D. Suggest weaning to allow the breast to heal.
A. Encourage warm compresses before feedings to promote milk flow.
Rationale: Warm compresses can promote milk flow, making feedings more comfortable and effective. Tight bras and decreased feeding frequency can worsen milk stasis and pain.
A client with mastitis expresses concern about continuing to breast-feed. What is the best response by the nurse?
A. “Frequent nursing will help clear the infection and relieve symptoms.”
B. “It’s best to stop breast-feeding until the infection resolves.”
C. “You should limit breast-feeding to the unaffected breast only.”
D. “Use formula feedings until the antibiotics take effect.”
A. “Frequent nursing will help clear the infection and relieve symptoms.”
Rationale: Frequent nursing or manual expression helps empty the breasts and prevent milk stasis, which is crucial in the treatment of mastitis.
The nurse is teaching a client with mastitis about controlling the infection. Which statement by the client indicates the need for further teaching?
A. “I can take antibiotics to treat the infection.”
B. “I should breast-feed more frequently to empty my breasts.”
C. “I will use ice packs only to reduce swelling and pain.”
D. “I’ll ensure my baby is latching properly during feedings.”
C. “I will use ice packs only to reduce swelling and pain.”
Rationale: Both ice packs and warm compresses can be used to manage pain and discomfort. Limiting to only ice packs may not provide optimal relief.
A postpartum client is diagnosed with mastitis and prescribed antibiotics. Which additional nursing intervention is most appropriate to include in the plan of care?
A. Advise the client to suppress lactation to prevent further complications.
B. Recommend using only warm packs to manage breast pain.
C. Suggest discontinuing breast-feeding from the affected breast.
D. Encourage frequent nursing or manual expression to empty the breasts.
D. Encourage frequent nursing or manual expression to empty the breasts.
Rationale: Frequent breast emptying through nursing or manual expression is essential to relieve milk stasis and promote recovery. Lactation suppression is not necessary, and both ice and warm packs may help with pain.
The nurse is educating a postpartum client about preventing mastitis. Which statement by the client demonstrates an understanding of the teaching?
A. “I should skip feedings on the affected breast to allow it to heal.”
B. “I’ll use soap and water to clean my nipples after each feeding.”
C. “I need to alternate breasts with each feeding and ensure proper latch.”
D. “I should wear a tight, supportive bra to reduce milk production.”
C. “I need to alternate breasts with each feeding and ensure proper latch.”
Rationale: Alternating breasts and ensuring proper latch reduces the risk of milk stasis and nipple trauma, both of which can lead to mastitis. Soap should be avoided as it can dry the nipples, and tight bras can contribute to milk stasis.
Which symptom reported by a client with mastitis should prompt the nurse to suspect a possible complication, such as a breast abscess?
A. Persistent fever despite antibiotic treatment.
B. Flu-like symptoms, including chills and body aches.
C. Mild tenderness and redness in one breast.
D. Distention of both breasts with milk.
A. Persistent fever despite antibiotic treatment.
Rationale: Persistent fever despite antibiotics may indicate a breast abscess, which requires additional treatment, such as drainage.
The nurse is teaching a client with mastitis about managing symptoms at home. Which statement indicates the need for further teaching?
A. “I will continue to breast-feed on the affected breast.”
B. “I can apply warm compresses before feeding to help milk flow.”
C. “I should take antibiotics as prescribed even if I start to feel better.”
D. “I’ll avoid touching or massaging the affected breast to reduce pain.”
D. “I’ll avoid touching or massaging the affected breast to reduce pain.”
Rationale: Gentle massaging of the affected breast can help relieve milk stasis and prevent further complications. Avoiding breast contact may exacerbate milk stasis and worsen symptoms.
A postpartum client presents with flu-like symptoms, fever, and a tender, hot, red area on her right breast. Which action should the nurse prioritize?
A. Encourage the client to stop breast-feeding and pump instead.
B. Recommend applying cold compresses to the affected area only.
C. Notify the healthcare provider and anticipate starting antibiotics.
D. Suggest restricting fluid intake to reduce milk production.
C. Notify the healthcare provider and anticipate starting antibiotics.
Rationale: Flu-like symptoms, fever, and a tender, hot, red breast area are hallmark signs of mastitis. Prompt antibiotic treatment is necessary to prevent complications such as an abscess.
During an assessment of a postpartum client, the nurse observes cracked skin around the nipples and complaints of breast tenderness. What is the nurse’s next best action?
A. Teach the client proper latch techniques for breast-feeding.
B. Advise the client to apply soap to the nipple area to keep it clean.
C. Encourage the client to decrease breast-feeding frequency.
D. Suggest abrupt weaning to prevent further irritation.
A. Teach the client proper latch techniques for breast-feeding.
Rationale: Cracked skin can increase the risk of mastitis, often caused by poor latch techniques. Proper latch education is key to preventing further complications.
A postpartum client reports redness, swelling, and pain in one breast, along with chills and a low-grade fever. Which additional symptom would confirm mastitis?
A. Distention of both breasts with milk.
B. A cracked nipple or areola on the affected breast.
C. Flu-like symptoms such as malaise and body aches.
D. Persistent engorgement despite regular feeding.
C. Flu-like symptoms such as malaise and body aches.
Rationale: Flu-like symptoms, along with localized breast tenderness, redness, and swelling, are hallmark signs of mastitis and differentiate it from normal engorgement or other breast issues.
The nurse is teaching a group of nursing students about cesarean birth risks. Which statement by a student requires correction?
A. “Cesarean births increase the risk of uterine atony.”
B. “Hemorrhage is a potential complication of cesarean birth.”
C. “A cesarean birth increases the risk of paralytic ileus.”
D. “Cesarean births pose no risk of infection to the client.”
D. “Cesarean births pose no risk of infection to the client.”
Rationale: Cesarean birth significantly increases the risk of infection due to the invasive nature of the procedure. Proper perioperative care is crucial to minimize this risk.
Which fetal complication is most commonly associated with cesarean birth?
A. Hypoglycemia.
B. Transient tachypnea of the newborn.
C. Fetal macrosomia.
D. Polycythemia.
B. Transient tachypnea of the newborn.
Rationale: Transient tachypnea of the newborn (TTN) is a common complication in neonates born via cesarean, as they do not experience the mechanical compression of the chest during vaginal delivery, which helps expel fluid from the lungs.
The nurse is caring for a client post-cesarean delivery. Which finding requires immediate intervention?
A. Slight redness around the incision site.
B. Pain rating of 5/10 controlled with analgesics.
C. Sudden shortness of breath and chest pain.
D. Minimal lochia serosa with no clots.
C. Sudden shortness of breath and chest pain.
Rationale: Sudden shortness of breath and chest pain may indicate a pulmonary embolism, a serious complication following cesarean birth.
Which maternal factor is most commonly associated with the need for a cesarean delivery?
A. Gestational hypertension.
B. Dystocia.
C. Multiple gestation.
D. Polyhydramnios.
B. Dystocia.
Rationale: Dystocia, or difficult labor, is one of the leading indications for cesarean delivery, along with previous cesarean birth, fetal distress, and breech presentation.
A postpartum client asks why she received epidural anesthesia during her cesarean birth instead of general anesthesia. Which explanation by the nurse is most accurate?
A. “Epidural anesthesia has fewer risks and allows you to remain awake for the birth experience.”
B. “General anesthesia is outdated and rarely used in cesarean deliveries.”
C. “Epidural anesthesia ensures the baby is born with minimal complications.”
D. “You had an epidural because it’s easier for the anesthesiologist to administer.”
A. “Epidural anesthesia has fewer risks and allows you to remain awake for the birth experience.”
Rationale: Epidural anesthesia is preferred for cesarean births because it poses fewer risks than general anesthesia and allows the mother to remain conscious during the birth.
A nurse is providing care to a client following a cesarean birth. Which complication is the client most at risk for?
A. Pulmonary embolism.
B. Prolonged labor.
C. Episiotomy infection.
D. Transient tachypnea of the newborn.
A. Pulmonary embolism.
Rationale: Cesarean birth is a major surgical procedure associated with risks such as infection, hemorrhage, pulmonary embolism, and thrombophlebitis.
Which client is at the highest risk for requiring a cesarean delivery?
A. A primigravida with a breech presentation.
B. A multipara with a history of vaginal deliveries.
C. A client with a body mass index (BMI) of 22.
D. A client experiencing spontaneous labor at 39 weeks.
A. A primigravida with a breech presentation.
Rationale: Breech presentation is a leading indication for cesarean delivery, especially in a primigravida.
Which factor is the most likely contributor to the rising cesarean birth rate in the United States?
A. Increased maternal parity.
B. Use of electronic fetal monitoring.
C. Decreased maternal obesity rates.
D. Reduction in malpractice suits.
B. Use of electronic fetal monitoring.
Rationale: The use of electronic fetal monitoring allows early identification of fetal distress, often leading to cesarean birth. Other contributors include increased maternal obesity, reduced forceps-assisted births, and convenience for providers.
A nurse is educating a pregnant client with a history of a prior cesarean birth about her delivery options. Which statement by the client indicates a need for further teaching?
A. “Because I’ve had one cesarean, there’s a 90% chance I’ll need another.”
B. “I’ll discuss the possibility of a vaginal birth after cesarean (VBAC) with my provider.”
C. “A previous cesarean birth guarantees I’ll have another one.”
D. “My provider will consider my health and pregnancy status when recommending delivery options.”
C. “A previous cesarean birth guarantees I’ll have another one.”
Rationale: While there is a high likelihood of a repeat cesarean after a primary cesarean, it is not guaranteed. Vaginal birth after cesarean (VBAC) may be an option depending on individual circumstances.
A nurse is reviewing the prenatal history of a client who is scheduled for a cesarean delivery due to dystocia. Which factor most likely contributed to this condition?
A. Advanced maternal age.
B. Multiparity.
C. History of cesarean delivery.
D. Fetopelvic disproportion.
D. Fetopelvic disproportion.
Rationale: Fetopelvic disproportion is a common cause of dystocia, as it prevents the fetus from safely passing through the birth canal.
A pregnant client with active genital herpes is admitted for delivery. Which nursing action is the priority?
A. Administer antiviral medication.
B. Obtain a culture of the lesions.
C. Notify the provider for cesarean delivery orders.
D. Monitor fetal heart rate continuously.
C. Notify the provider for cesarean delivery orders.
Rationale: Active genital herpes requires cesarean delivery to prevent neonatal infection with the herpes simplex virus.
The nurse is educating a pregnant client with a history of malpresentation. Which of the following statements about cesarean birth is accurate?
A. “All malpresentations require cesarean delivery.”
B. “Cesarean birth is always the safest option for malpresentation.”
C. “Certain malpresentations, such as breech, often require cesarean delivery.”
D. “Malpresentation is rarely a cause for concern during labor.”
C. “Certain malpresentations, such as breech, often require cesarean delivery.”
Rationale: Certain malpresentations, like breech or transverse lie, often necessitate cesarean delivery to ensure maternal and fetal safety.
A nurse is assessing a pregnant client with a history of cesarean birth. Which condition in the client’s history is a contraindication for a vaginal birth after cesarean (VBAC)?
A. Gestational diabetes.
B. Previous classic uterine incision.
C. Positive HIV status.
D. Gestational hypertension.
B. Previous classic uterine incision.
Rationale: A previous classic uterine incision increases the risk of uterine rupture, making VBAC contraindicated.
Which of the following conditions is considered an absolute indication for a cesarean birth?
A. Active genital herpes.
B. Oligohydramnios.
C. Advanced maternal age.
D. Preterm labor.
A. Active genital herpes.
Rationale: Active genital herpes during labor poses a significant risk of neonatal infection, necessitating cesarean delivery.
A nurse is counseling a pregnant woman who is considering an elective cesarean birth. Which statement by the woman requires further clarification?
A. “I understand that this choice could increase risks for future pregnancies.”
B. “This decision is entirely up to my provider.”
C. “I have the right to choose this route after learning about the risks and benefits.”
D. “I’ll discuss this option further with my provider to make an informed choice.”
B. “This decision is entirely up to my provider.”
Rationale: The decision for an elective cesarean birth should be made collaboratively, with the woman actively involved after receiving evidence-based counseling.
Which fetal condition is most likely to require a cesarean delivery?
A. Fetal macrosomia.
B. Mild polyhydramnios.
C. Occiput anterior position.
D. Vertex presentation.
A. Fetal macrosomia.
Rationale: Fetal macrosomia increases the risk of fetopelvic disproportion and complications during vaginal delivery, often necessitating a cesarean birth.
A pregnant client with placenta previa is scheduled for a cesarean delivery. Which statement by the client indicates understanding of the procedure?
A. “I can attempt a vaginal delivery if I go into labor naturally.”
B. “Placenta previa occurs because I’ve had too much amniotic fluid.”
C. “After this delivery, I won’t need any follow-up ultrasounds.”
D. “Placenta previa means my baby’s placenta is covering my cervix.”
D. “Placenta previa means my baby’s placenta is covering my cervix.”
Rationale: Placenta previa occurs when the placenta partially or completely covers the cervix, requiring cesarean delivery to prevent complications.
What is the primary nursing focus when preparing a client for a cesarean birth?
A. Preparing the surgical equipment.
B. Monitoring the fetal heart rate.
C. Ensuring the woman understands the procedure and feels supported.
D. Collecting all necessary diagnostic tests.
C. Ensuring the woman understands the procedure and feels supported.
Rationale: The nurse’s primary focus should be on the client’s emotional and informational needs to ensure she feels supported and prepared for the procedure.
Which nursing intervention best supports a positive birth experience for a client undergoing a cesarean delivery?
A. Focusing on technical tasks to ensure surgical precision.
B. Using therapeutic communication and showing genuine care.
C. Minimizing touch to maintain a sterile environment.
D. Allowing the client to remain alone during preoperative preparation.
B. Using therapeutic communication and showing genuine care.
Rationale: Therapeutic communication, touch, and genuine care help reduce anxiety and create a supportive environment, enhancing the client’s birth experience.
A client expresses anxiety about her upcoming cesarean birth. What is the nurse’s best response?
A. “Let me explain the procedure and answer any questions you have.”
B. “It’s a routine procedure, so there’s nothing to worry about.”
C. “You should trust the surgical team to take care of everything.”
D. “I’ll give you medication to help you relax before the surgery.”
A. “Let me explain the procedure and answer any questions you have.”
Rationale: Providing education and addressing the client’s questions helps alleviate anxiety by promoting understanding and involvement in her care.
During the preparation for a cesarean birth, the nurse emphasizes the importance of family-centered care. Which action best demonstrates this principle?
A. Explaining the surgical procedure in detail to the client.
B. Limiting the partner’s presence to avoid interference.
C. Keeping the mother, partner, and newborn together whenever possible.
D. Ensuring that the surgical team operates efficiently and quickly.
C. Keeping the mother, partner, and newborn together whenever possible.
Rationale: Family-centered care involves minimizing separation between the mother, partner, and newborn to support bonding and provide emotional comfort.
A nurse is preparing a client for a cesarean birth. Which preoperative diagnostic test is essential to ensure blood availability in case of hemorrhage?
A. Urinalysis
B. Complete blood count
C. Blood type and cross-match
D. Coagulation studies
C. Blood type and cross-match
Rationale: Blood type and cross-match are performed to ensure that compatible blood is available for transfusion if necessary during or after the cesarean birth.
Which diagnostic test is most appropriate to determine fetal lung maturity before a scheduled cesarean birth?
A. Amniocentesis
B. Complete blood count
C. Urinalysis
D. Ultrasound
A. Amniocentesis
Rationale: Amniocentesis is performed to assess fetal lung maturity if there is a need to deliver the fetus before 39 weeks of gestation.
Which of the following actions should be performed by the nurse during the preoperative care of a client scheduled for a cesarean birth?
A. Ask the client to fast for 12 hours prior to surgery.
B. Administer preoperative medications as ordered and document the time and client’s reaction.
C. Insert a urinary catheter only if instructed by the surgeon.
D. Delay the intravenous infusion until the client is in the operating room.
B. Administer preoperative medications as ordered and document the time and client’s reaction.
Rationale: Administering preoperative medications as ordered and documenting the time and reaction is a key part of ensuring the client is prepared for surgery and that any medication response is properly documented.
A nurse is instructing a client on how to splint her incision after a cesarean birth. What is the primary purpose of this technique?
A. To prevent the incision from becoming infected
B. To prevent bleeding from the incision site
C. To accelerate the healing of the surgical wound
D. To reduce pain and tension on the incision during coughing or movement
D. To reduce pain and tension on the incision during coughing or movement
Rationale: Splinting the incision helps reduce pain and tension during activities such as coughing or movement, which is crucial for comfort and recovery.
Which of the following actions is most important when a nurse is performing preoperative teaching to reduce postoperative complications for a cesarean birth?
A. Instructing the client on the proper use of the incentive spirometer
B. Providing detailed information about the expected postoperative pain medications
C. Ensuring the client’s family is aware of the expected recovery time
D. Explaining the importance of restricting oral intake before surgery
A. Instructing the client on the proper use of the incentive spirometer
Rationale: Teaching the use of the incentive spirometer, deep breathing, and leg exercises are important preoperative measures to reduce postoperative complications such as atelectasis and thrombosis.
A nurse is preparing a client for a cesarean birth. Which task is included in preoperative care?
A. Discussing anesthesia options in detail.
B. Preparing the surgical site as ordered.
C. Administering an epidural after the procedure.
D. Starting a continuous fetal monitoring after surgery.
B. Preparing the surgical site as ordered.
Rationale: Preparing the surgical site as ordered is a key preoperative task to ensure the area is sterile and ready for the surgery.
Which of the following should be assessed by the nurse before an unplanned cesarean birth?
A. The client’s and family’s understanding of the procedure and expectations.
B. The client’s knowledge of common cesarean complications.
C. The presence of any preexisting surgical scars unrelated to pregnancy.
D. The client’s preference for anesthesia options during the procedure.
A. The client’s and family’s understanding of the procedure and expectations.
Rationale: Assessing the client’s and family’s understanding of the procedure helps guide the teaching and emotional support process before surgery.
What is the nurse’s role in preoperative teaching for a client undergoing a cesarean birth?
A. Provide only basic instructions to the client about the procedure.
B. Focus only on postoperative care, as the procedure is well understood.
C. Leave all teaching to the surgeon, as they are the primary educator.
D. Offer detailed explanations to reduce anxiety and ensure understanding of the surgery.
D. Offer detailed explanations to reduce anxiety and ensure understanding of the surgery.
Rationale: Detailed explanations, including what to expect during and after the surgery, help reduce anxiety and promote understanding of the procedure.
A nurse is preparing a client for an unplanned cesarean birth. Which action should the nurse prioritize to ensure the best outcomes for the mother and fetus?
A. Administer preoperative medications as ordered
B. Ensure that the partner is prepared for the surgery
C. Discuss the procedure in detail with the surgical team
D. Initiate the informed consent process as soon as possible
D. Initiate the informed consent process as soon as possible
Rationale: In an unplanned cesarean birth, ensuring the woman has signed the informed consent quickly and addressing her fears and expectations are crucial for the best outcomes.
Which action should the nurse prioritize in the immediate postoperative period for a client who has undergone a cesarean delivery?
A. Monitor vital signs and lochia flow every 15 minutes for the first hour.
B. Administer pain medication every 4 hours.
C. Assess for abdominal distention every 8 hours.
D. Encourage early ambulation within the first 24 hours.
A. Monitor vital signs and lochia flow every 15 minutes for the first hour.
Rationale: In the immediate postoperative period, monitoring vital signs and lochia flow every 15 minutes for the first hour is essential for early identification of any complications such as hemorrhage.
A nurse is assessing a postpartum cesarean patient and notices redness at the intravenous (IV) infusion site. What is the nurse’s next step?
A. Document the redness and continue the IV infusion.
B. Check the patency of the IV line and inspect for any other signs of infection.
C. Apply an ice pack to the IV site and continue to monitor.
D. Discontinue the IV infusion immediately and notify the physician.
B. Check the patency of the IV line and inspect for any other signs of infection.
Rationale: Redness at the IV site may indicate infection or irritation. The nurse should check the IV line’s patency and inspect for further signs of complications, such as swelling or warmth, before making decisions.
A postpartum cesarean client has received regional anesthesia. Which of the following should the nurse specifically monitor in the immediate postoperative period?
A. Oxygen saturation levels and heart rate.
B. Return of sensation to the legs.
C. Blood pressure and respiratory rate.
D. Lochia flow and uterine tone.
B. Return of sensation to the legs.
Rationale: After regional anesthesia, the nurse should monitor the return of sensation to the legs to ensure that the anesthesia is wearing off and to assess for any complications such as nerve injury or delayed sensation recovery.
Which nursing intervention is appropriate to promote early recovery and prevent complications in a cesarean delivery client?
A. Assist with perineal care and encourage frequent use of the incentive spirometer.
B. Encourage bed rest and limit fluid intake.
C. Administer antibiotics and pain medications as ordered.
D. Assist with early ambulation and encourage deep breathing exercises every 2 hours.
D. Assist with early ambulation and encourage deep breathing exercises every 2 hours.
Rationale: Early ambulation and frequent deep breathing exercises help prevent respiratory and cardiovascular complications, as well as promote peristalsis and venous return from the extremities.
The nurse is helping a postpartum cesarean client initiate breastfeeding. What is an appropriate action to reduce discomfort while breastfeeding?
A. Encourage the mother to use a side-lying position to minimize pressure on the incision site.
B. Have the mother sit upright and lift the baby to the breast.
C. Provide a pillow for support and encourage the mother to breastfeed while standing.
D. Ask the mother to avoid breast-feeding until her incision heals completely.
A. Encourage the mother to use a side-lying position to minimize pressure on the incision site.
Rationale: A side-lying position helps reduce pressure on the incision site, enhancing comfort while breastfeeding after a cesarean delivery.
A postpartum cesarean client is preparing for discharge. Which of the following should the nurse teach her to prevent complications after returning home?
A. Limit fluid intake to avoid bladder retention.
B. Encourage bed rest and restrict ambulation for 2 weeks.
C. Refrain from using the incentive spirometer once home.
D. Perform light activities, but avoid lifting for at least 6 weeks.
D. Perform light activities, but avoid lifting for at least 6 weeks.
Rationale: The nurse should encourage light activity, but advise the client to avoid lifting or strenuous activity for at least 6 weeks to promote healing and prevent complications like incisional hernia or strain.
During the postoperative period following a cesarean delivery, the nurse notes that the client’s fundus is soft and displaced to the right. What is the most appropriate action for the nurse to take?
A. Administer pain medication and continue monitoring.
B. Have the client void and then reassess the fundus.
C. Document the finding as normal after cesarean delivery.
D. Apply gentle massage to the fundus to promote uterine contraction.
B. Have the client void and then reassess the fundus.
Rationale: A soft and displaced fundus may indicate bladder distention. The nurse should first have the client void to see if this resolves the issue before taking further action.
Which of the following is the nurse’s priority action immediately after a cesarean birth in the recovery room (PACU)?
A. Encourage early skin-to-skin contact between the mother and newborn.
B. Offer the client fluids and food to promote recovery.
C. Assess the client’s level of anxiety and provide reassurance.
D. Perform a fundal check and assess the incision site for signs of bleeding.
D. Perform a fundal check and assess the incision site for signs of bleeding.
Rationale: Immediately after cesarean delivery, the nurse should first assess the fundus and incision site for bleeding to ensure the client’s immediate postoperative stability.
The nurse is teaching a client about pain management following cesarean birth. Which of the following is the most important point to emphasize?
A. Pain management will not be necessary once the client can sit up and move.
B. Pain should be managed with oral medications only, to avoid complications from IV narcotics.
C. The client should request pain medication before pain becomes severe.
D. Pain relief should be avoided to encourage early mobilization and reduce complications.
C. The client should request pain medication before pain becomes severe.
Rationale: Early and proactive pain management is key to preventing the escalation of pain. The client should be encouraged to request pain medication before the pain becomes severe, which can help facilitate better recovery and mobilization.
The nurse is preparing a client for a cesarean delivery. What is the primary reason for maintaining NPO status before surgery?
A. To prevent the risk of aspiration during anesthesia.
B. To reduce the chances of uterine hemorrhage during the procedure.
C. To minimize the need for postoperative pain medications.
D. To prepare the client for a general anesthesia procedure.
A. To prevent the risk of aspiration during anesthesia.
Rationale: NPO status is required to reduce the risk of aspiration during anesthesia. This is a safety precaution that helps prevent complications related to airway management during surgery.
A client is being admitted for a cesarean birth. Which of the following is an essential nursing action to ensure the client’s safety during preoperative preparation?
A. Administer pain medication before the procedure to reduce anxiety.
B. Start an IV infusion for fluid replacement therapy as ordered.
C. Discontinue all medications the client is taking, including prenatal vitamins.
D. Restrict the client’s fluid intake for the next 48 hours.
B. Start an IV infusion for fluid replacement therapy as ordered.
Rationale: Starting an IV infusion for fluid replacement therapy is essential for maintaining hydration and supporting the client’s circulatory needs during the procedure.
A client undergoing cesarean delivery with a low transverse incision is in the postoperative period. Which of the following actions is most important to assess in the first few hours after surgery?
A. Monitor the client’s intake and output for signs of fluid overload.
B. Assess the client’s level of consciousness and return of sensation from spinal anesthesia.
C. Encourage the client to refrain from ambulation for the first 24 hours.
D. Provide instruction on breastfeeding as the first priority.
B. Assess the client’s level of consciousness and return of sensation from spinal anesthesia.
Rationale: In the immediate postoperative period, assessing the return of sensation from spinal anesthesia is critical to ensure the client is fully alert and responsive before initiating ambulation or other activities.
A client is undergoing a cesarean delivery with a classic uterine incision. Which of the following is the most important consideration for the nurse during the postoperative period?
A. Ensure the client does not breastfeed for 24 hours.
B. Encourage early ambulation to prevent respiratory complications.
C. Discontinue pain management medications once the client is awake.
D. Monitor for signs of uterine rupture in future pregnancies.
D. Monitor for signs of uterine rupture in future pregnancies.
Rationale: A classic uterine incision increases the risk of uterine rupture in future pregnancies. The nurse should educate the client about this risk and the need for careful monitoring during subsequent pregnancies.
A client is being prepared for a cesarean delivery with a low transverse incision. Which preoperative action should the nurse prioritize?
A. Shaving the client’s pubic area.
B. Inserting an indwelling catheter only if the client is unable to void.
C. Preparing the client for a long recovery period due to a high incision.
D. Administering prophylactic antibiotics as ordered.
D. Administering prophylactic antibiotics as ordered.
Rationale: Prophylactic antibiotics are commonly administered to reduce the risk of infection during a cesarean delivery, regardless of the type of incision.
A woman with a prior cesarean birth is undergoing a trial of labor after cesarean (TOLAC). The nurse notes that the cervix is dilating slowly, and there are signs of fetal distress. What is the nurse’s priority action?
A. Administer additional doses of Pitocin to accelerate labor.
B. Provide the woman with comfort measures and allow more time for labor progression.
C. Notify the healthcare provider and prepare for an emergency cesarean birth.
D. Encourage the woman to change positions to improve fetal oxygenation.
C. Notify the healthcare provider and prepare for an emergency cesarean birth.
Rationale: Slow cervical dilation with signs of fetal distress in a woman attempting TOLAC may indicate complications such as uterine rupture. The priority is to notify the healthcare provider and prepare for a cesarean delivery to ensure the safety of both mother and baby.
A nurse is educating a woman about the risks of attempting a vaginal birth after cesarean (VBAC). Which of the following statements would be accurate?
A. “The risk of uterine rupture is negligible, and a VBAC is always safe.”
B. “You are more likely to experience a cesarean birth again than to have a successful vaginal delivery.”
C. “A VBAC is contraindicated if you had a low transverse incision with your previous cesarean.”
D. “Your risk of uterine rupture is lower if you had a classical uterine incision with your previous cesarean.”
B. “You are more likely to experience a cesarean birth again than to have a successful vaginal delivery.”
Rationale: The risk of uterine rupture is higher during VBAC than in a first-time vaginal delivery, and the likelihood of a repeat cesarean is approximately 90% if a previous cesarean was performed.
A woman undergoing a trial of labor after cesarean (TOLAC) develops sudden, severe abdominal pain and vaginal bleeding. The fetal heart rate shows decelerations. What should the nurse immediately suspect?
A. Placental abruption
B. Uterine rupture
C. Uterine atony
D. Postpartum hemorrhage
B. Uterine rupture
Rationale: Sudden severe abdominal pain, vaginal bleeding, and fetal heart rate decelerations are classic signs of uterine rupture. Immediate intervention is necessary to manage this life-threatening emergency.
Which of the following is true regarding the use of Pitocin for augmentation in a woman attempting vaginal birth after cesarean (VBAC)?
A. High doses of Pitocin are preferred for efficient labor progression.
B. Pitocin is contraindicated for all VBAC candidates.
C. Pitocin use is not associated with an increased risk of uterine rupture.
D. Pitocin should be used only in low doses and with close monitoring.
D. Pitocin should be used only in low doses and with close monitoring.
Rationale: Pitocin can be used in VBAC but must be administered at low doses with continuous monitoring to minimize the risk of uterine rupture.
A woman is in labor after a previous cesarean delivery and has a low transverse uterine incision. Which of the following complications is the nurse most concerned about during the second stage of labor?
A. Uterine rupture due to excessive contraction stimulation.
B. Shoulder dystocia due to fetal malpresentation.
C. Incomplete cervical dilation despite uterine contractions.
D. Placenta previa due to abnormal placental implantation.
A. Uterine rupture due to excessive contraction stimulation.
Rationale: Uterine rupture is a significant concern during the second stage of labor in a woman with a previous cesarean delivery, especially if excessive contraction stimulation occurs or if labor is poorly monitored.
A woman with one previous cesarean delivery is attempting a trial of labor after cesarean (TOLAC). Which of the following is the most appropriate action for the nurse during the first stage of labor?
A. Discontinue fetal monitoring once labor is well-established.
B. Administer misoprostol for cervical ripening as ordered by the provider.
C. Monitor the fetal heart rate continuously and observe for signs of uterine rupture.
D. Encourage the client to remain in a supine position throughout labor.
C. Monitor the fetal heart rate continuously and observe for signs of uterine rupture.
Rationale: Continuous fetal heart rate monitoring is essential during TOLAC to detect signs of fetal distress or uterine rupture. Monitoring and close supervision are necessary for a safe labor and delivery.
A woman with a history of one previous cesarean delivery is considering a vaginal birth after cesarean (VBAC). Which of the following is a requirement for the woman to be eligible for a VBAC?
A. The woman must have a classical uterine incision during her previous cesarean.
B. She must have a history of successful vaginal births.
C. Documentation of a low transverse uterine incision from the previous cesarean.
D. The woman must have a low-risk pregnancy without any current medical complications.
C. Documentation of a low transverse uterine incision from the previous cesarean.
Rationale: A low transverse uterine incision (Pfannenstiel incision) is required for VBAC eligibility. Classical or transverse incisions increase the risk of uterine rupture, making VBAC contraindicated.
Which of the following interventions is contraindicated for cervical ripening in a woman planning a trial of labor after cesarean (TOLAC)?
A. Misoprostol
B. Low-dose Pitocin
C. Amniotomy
D. Membrane sweeping
A. Misoprostol
Rationale: Misoprostol is contraindicated for cervical ripening in women attempting VBAC or TOLAC due to the increased risk of uterine rupture.
A woman with a prior cesarean delivery is considering a trial of labor after cesarean (TOLAC). Which of the following is an essential component of her care plan?
A. Immediate vaginal delivery without the option for cesarean birth.
B. Use of high-dose Pitocin to enhance uterine contractions.
C. Complete restriction of oral intake during labor.
D. Continuous fetal monitoring and close supervision during labor.
D. Continuous fetal monitoring and close supervision during labor.
Rationale: Women undergoing TOLAC require continuous fetal monitoring and close supervision of labor to identify signs of uterine rupture or other complications, and allow for rapid intervention if a cesarean birth is needed.
What is the primary risk of uterine rupture in a woman undergoing vaginal birth after cesarean (VBAC)?
A. Increased maternal blood loss during delivery.
B. Risk of fetal distress due to prolonged labor.
C. Decreased uterine tone leading to hemorrhage.
D. Disruption of the uterine scar from the previous cesarean.
D. Disruption of the uterine scar from the previous cesarean.
Rationale: The primary risk of uterine rupture in VBAC is the disruption of the uterine scar from the previous cesarean, which can lead to serious maternal and fetal complications.
The nurse is caring for a patient in labor with a history of cesarean delivery and suspected uterine rupture. Which of the following is the most important maternal vital sign to monitor closely in this situation?
A. Blood pressure
B. Temperature
C. Respiratory rate
D. Pulse oximetry
A. Blood pressure
Rationale: Blood pressure is crucial to monitor closely as hypotension can indicate hypovolemic shock, a potentially life-threatening complication that may occur with uterine rupture.
When preparing for an emergency cesarean birth due to suspected uterine rupture, which of the following actions should the nurse prioritize in addition to preparing the operating room and alerting the neonatal team?
A. Assess fetal heart tones every 5 minutes
B. Inform the woman of the seriousness of the situation
C. Perform an immediate vaginal exam
D. Administer antibiotics to prevent infection
B. Inform the woman of the seriousness of the situation
Rationale: It is essential to inform the woman about the seriousness of the situation while providing reassurance. Clear communication helps manage anxiety and ensures the woman is aware of the steps being taken.
A woman in labor with a previous cesarean delivery is exhibiting signs of uterine rupture. The nurse observes hypotension and tachycardia. What is the priority action in this situation?
A. Administer oxygen to the woman
B. Insert an indwelling urinary catheter
C. Monitor fetal heart tones closely
D. Prepare the operating room and alert the surgical team
D. Prepare the operating room and alert the surgical team
Rationale: The presence of hypotension and tachycardia suggests hypovolemic shock, which requires rapid intervention. Preparing the operating room and alerting the surgical team for an emergency cesarean is the priority action.
A woman with a history of cesarean delivery experiences sudden fetal distress. The nurse suspects uterine rupture. Which of the following is the most critical initial intervention for the nurse to prioritize?
A. Administer intravenous fluids to the mother
B. Prepare for an emergency cesarean delivery
C. Administer pain medication to the mother
D. Perform a vaginal examination to assess for fetal position
B. Prepare for an emergency cesarean delivery
Rationale: In the case of uterine rupture, the most critical intervention is to prepare for an emergency cesarean delivery to ensure the health of both the mother and the fetus.
The nurse is caring for a woman with a history of cesarean delivery. She is in labor and experiencing acute abdominal pain. The nurse observes no fetal heart tones on the monitor. What is the priority action?
A. Administer an analgesic to relieve the woman’s pain.
B. Prepare for an emergency cesarean delivery.
C. Increase the frequency of fetal heart rate monitoring.
D. Assess for vaginal bleeding or hematuria.
B. Prepare for an emergency cesarean delivery.
Rationale: The absence of fetal heart tones, especially in the context of acute abdominal pain, raises suspicion for uterine rupture. The priority action is to prepare for an emergency cesarean delivery to address fetal distress and maternal complications.
A woman with a history of previous uterine surgery is admitted for labor. The nurse should assess her for which of the following risk factors related to uterine rupture?
A. Previous uterine myomectomy
B. Use of electronic fetal monitoring
C. Labor induction with low-dose Pitocin
D. History of gestational diabetes
A. Previous uterine myomectomy
Rationale: A previous uterine myomectomy (removal of fibroids) can create scarring and increase the risk of uterine rupture during subsequent labor. This should be a key consideration during the assessment.
Which of the following interventions is most critical for detecting uterine rupture in a woman attempting a trial of labor after cesarean (TOLAC)?
A. Continuous electronic fetal monitoring
B. Frequent abdominal palpation
C. Immediate delivery by cesarean
D. Administering pain medications for comfort
A. Continuous electronic fetal monitoring
Rationale: Continuous electronic fetal monitoring is essential during TOLAC, as it provides real-time indications of fetal distress, which is often the first sign of uterine rupture.
Which of the following risk factors should the nurse prioritize when assessing a woman in labor who has a history of cesarean delivery?
A. Malpresentation
B. Previous uterine myomectomy
C. History of placenta percreta
D. Crack cocaine use
C. History of placenta percreta
Rationale: A history of placenta percreta significantly increases the risk of uterine rupture and should be prioritized when assessing risk. This condition leads to the abnormal attachment of the placenta to the uterine wall and can complicate labor and delivery.
A nurse is assessing a postpartum woman who is at risk for hemorrhage. What is the most accurate definition of primary postpartum hemorrhage (PPH)?
A. Blood loss greater than 1,000 mL occurring within 24 hours of birth, with signs of hypovolemia
B. Blood loss greater than 500 mL occurring within 24 hours of birth
C. Blood loss greater than 1,500 mL occurring within the first 6 hours of birth
D. Blood loss greater than 500 mL occurring after 12 weeks postpartum
A. Blood loss greater than 1,000 mL occurring within 24 hours of birth, with signs of hypovolemia
Rationale: Primary postpartum hemorrhage is defined as blood loss greater than 1,000 mL within 24 hours of delivery, with signs of hypovolemia, which can lead to serious complications.
Postpartum hemorrhage (PPH) occurs in 5% of all births. Which of the following is the most common sequela of severe PPH?
A. Sepsis
B. Acute respiratory distress
C. Organ failure
D. Anemia
D. Anemia
Rationale: Anemia is a common sequela of severe postpartum hemorrhage due to significant blood loss, leading to a decrease in hemoglobin and hematocrit levels.
A nurse is reviewing the patient’s history to assess risk factors for postpartum hemorrhage (PPH). Which of the following is a known risk factor for PPH?
A. A history of cesarean delivery
B. Use of hormonal contraception
C. A BMI under 18.5
D. Delivery by vacuum extraction
A. A history of cesarean delivery
Rationale: A history of cesarean delivery increases the risk for postpartum hemorrhage due to factors such as uterine scarring and possible complications during delivery.
A patient is experiencing primary postpartum hemorrhage, with blood loss greater than 1,000 mL within 24 hours of delivery. The nurse recognizes the potential for severe complications. Which of the following interventions is most important in preventing morbidity related to PPH?
A. Administering a prophylactic antibiotic
B. Initiating fluid resuscitation and blood transfusions as needed
C. Encouraging early breastfeeding to stimulate uterine contractions
D. Monitoring vital signs every hour for the first 12 hours
B. Initiating fluid resuscitation and blood transfusions as needed
Rationale: Initiating fluid resuscitation and blood transfusions promptly is critical to stabilize the patient and prevent complications such as shock, organ failure, and anemia.
A woman who has just given birth experiences significant bleeding. The nurse determines that postpartum hemorrhage (PPH) is likely. What is the primary cause of most maternal deaths related to PPH in both developed and developing countries?
A. Infection
B. Blood clots
C. Inadequate uterine contraction
D. Organ failure
C. Inadequate uterine contraction
Rationale: The most common cause of postpartum hemorrhage is inadequate uterine contraction, which leads to uterine atony and excessive bleeding. This condition is preventable with proper management.
A nurse is caring for a postpartum patient who has experienced a significant blood loss during childbirth. Which of the following is the most important intervention to prevent further complications from postpartum hemorrhage (PPH)?
A. Administer a blood transfusion immediately
B. Monitor the mother for signs of hypovolemic shock
C. Encourage early ambulation to prevent thrombosis
D. Place the mother in the lithotomy position for better uterine tone
B. Monitor the mother for signs of hypovolemic shock
Rationale: Monitoring for signs of hypovolemic shock is crucial to assess the severity of postpartum hemorrhage and guide timely intervention, such as fluid resuscitation and blood transfusion, as necessary.
A woman undergoing a vaginal delivery has an increased risk of postpartum hemorrhage due to retained blood clots. What is the most likely intervention to address this complication?
A. Immediate uterine massage
B. Administration of methylergonovine
C. Manual removal of the retained clots
D. Application of ice to the perineum
C. Manual removal of the retained clots
Rationale: Retained blood clots can prevent the uterus from contracting effectively and cause excessive bleeding. Manual removal of the clots may be necessary to stop the hemorrhage.
A woman has delivered via cesarean section and is at risk for postpartum hemorrhage due to uterine trauma. Which of the following factors would most likely contribute to the risk of hemorrhage in this patient?
A. Previous uterine surgery
B. Use of a vacuum extractor during delivery
C. History of preeclampsia
D. Maternal age over 35
A. Previous uterine surgery
Rationale: Previous uterine surgery, such as a cesarean section, increases the risk for uterine trauma, such as scarring or rupture, which can lead to postpartum hemorrhage.
A postpartum patient is at risk for hemorrhage due to uterine atony. Which of the following is a primary intervention to promote uterine contraction and reduce the risk of hemorrhage?
A. Encourage the patient to ambulate
B. Administer an oxytocin infusion
C. Perform a uterine massage every hour
D. Provide a high-protein diet to the patient
B. Administer an oxytocin infusion
Rationale: Oxytocin is a uterotonic medication that promotes uterine contractions, which are essential in preventing and controlling postpartum hemorrhage due to uterine atony.
A patient with a history of idiopathic thrombocytopenia purpura (ITP) has just delivered. Which of the following would be the most appropriate action to prevent excessive bleeding in this patient?
A. Administering intravenous fluids
B. Applying pressure to the perineum during delivery
C. Monitoring platelet levels closely
D. Initiating oxytocin immediately post-delivery
C. Monitoring platelet levels closely
Rationale: Idiopathic thrombocytopenia purpura (ITP) results in low platelet levels, increasing the risk of bleeding. Monitoring platelet levels closely and preparing for possible transfusion are key interventions to manage bleeding risk.
A postpartum patient is at risk for hemorrhage due to uterine overdistention. Which of the following conditions places the patient at the greatest risk for this complication?
A. Polyhydramnios
B. Precipitate birth
C. Uterine inversion
D. Previous cesarean section
A. Polyhydramnios
Rationale: Polyhydramnios (excessive amniotic fluid) causes uterine overdistention, increasing the risk for uterine muscle exhaustion and decreased uterine tone, which can lead to postpartum hemorrhage.
A nurse is caring for a postpartum patient who has experienced heavy bleeding and suspects the presence of disseminated intravascular coagulation (DIC). Which of the following factors would most likely contribute to the development of DIC in this patient?
A. Hemophilia
B. Prolonged rupture of membranes
C. History of thrombocytopenia
D. Rapid labor and delivery
B. Prolonged rupture of membranes
Rationale: Prolonged rupture of membranes increases the risk for infection and inflammatory response, which can trigger DIC, a coagulopathy that leads to widespread clotting and hemorrhage.
A woman who experienced a precipitous birth is at increased risk for postpartum hemorrhage. Which of the following is the most likely cause of hemorrhage in this situation?
A. Uterine rupture
B. Lacerations of the genital tract
C. Retained placenta
D. Uterine infection
B. Lacerations of the genital tract
A woman has a history of von Willebrand disease and is at risk for postpartum hemorrhage (PPH). Which of the following interventions is most critical to prevent excessive bleeding in this patient?
A. Administer oxytocin to ensure uterine contraction
B. Apply perineal pressure to manage vaginal bleeding
C. Monitor for signs of uterine inversion
D. Avoid any forceful traction on the umbilical cord
D. Avoid any forceful traction on the umbilical cord
Rationale: Avoiding forceful traction on the umbilical cord is crucial in preventing uterine trauma, which could exacerbate bleeding, especially in patients with coagulation abnormalities such as von Willebrand disease.
A postpartum patient is diagnosed with an incomplete placenta at birth, which is placing her at risk for hemorrhage. What is the most likely consequence of this condition?
A. Atonic uterus
B. Uterine inversion
C. Laceration of the cervix
D. Retained products of conception
D. Retained products of conception
Rationale: An incomplete placenta at birth is considered a retained product of conception, which can lead to postpartum hemorrhage due to the continued presence of tissue in the uterus, preventing full uterine contraction.
A nurse is assessing a postpartum patient and notices that the uterus is not contracting effectively, resulting in an increased risk for postpartum hemorrhage. Which of the following factors most likely contributed to this patient’s condition?
A. Macrosomia
B. Prolonged rupture of membranes
C. Use of oxytocin
D. History of previous cesarean section
A. Macrosomia
Rationale: Macrosomia, or a larger-than-average baby, increases the risk of uterine overdistention, which can lead to uterine muscle exhaustion and poor contraction, increasing the risk for postpartum hemorrhage.
A nurse is assessing a postpartum patient with a history of prolonged labor. The nurse identifies that the patient is at increased risk for which of the following complications?
A. Uterine atony
B. Postpartum infection
C. Uterine rupture
D. DVT (deep vein thrombosis)
A. Uterine atony
Rationale: Prolonged labor can lead to uterine muscle fatigue and uterine atony, which increases the risk of postpartum hemorrhage.
A nurse is caring for a postpartum patient with signs of hypovolemic shock. Which of the following symptoms would be expected?
A. Decreased pulse rate and normal blood pressure
B. Hypotension, tachycardia, and decreased level of consciousness
C. Elevated blood pressure and fever
D. Decreased respiratory rate and dizziness
B. Hypotension, tachycardia, and decreased level of consciousness
Rationale: Hypovolemic shock typically presents with hypotension, tachycardia, and decreased consciousness, which are signs of inadequate perfusion due to significant blood loss.
A postpartum patient is found to have bright red bleeding with a firm uterus and no obvious lacerations. The nurse suspects a hematoma is present. Which of the following is the most likely sign of this condition?
A. Increased uterine tone and heavy blood loss
B. Severe perineal pain and a localized bulge in the perineum
C. Absence of pain with moderate blood loss
D. Decreased blood pressure and cyanosis
B. Severe perineal pain and a localized bulge in the perineum
Rationale: Hematomas are associated with severe perineal pain and a localized bulge in the perineum, often requiring surgical intervention for evacuation.
A nurse is assessing a postpartum patient for signs of hemorrhage. Which of the following findings would be most concerning in identifying early postpartum hemorrhage (PPH)?
A. Increased pulse rate and decreased blood pressure
B. Soft, boggy uterus with dark red bleeding
C. Firm uterus with steady bright red bleeding
D. Blurred vision and confusion
B. Soft, boggy uterus with dark red bleeding
Rationale: A soft, boggy uterus with dark red bleeding is a hallmark of uterine atony, the most common cause of early postpartum hemorrhage. Immediate intervention is needed to prevent further complications.
A postpartum patient presents with severe perineal pain and difficulty voiding. On examination, the nurse identifies a localized bluish bulge under the skin surface in the perineum. What is the most likely diagnosis?
A. Hematoma
B. Uterine inversion
C. Uterine atony
D. Retained placenta
A. Hematoma
Rationale: A hematoma in the perineal area, often seen with operative deliveries, presents as a bluish bulge and is associated with severe perineal pain, difficulty voiding, and signs of blood loss.
A nurse is assessing a postpartum patient with diminished urinary output and signs of acute renal failure. Which of the following should the nurse be concerned about as a potential cause?
A. Disseminated intravascular coagulation (DIC)
B. Postpartum infection
C. Retained placenta
D. Severe blood loss leading to shock
D. Severe blood loss leading to shock
Rationale: Severe blood loss can lead to hypovolemic shock, which affects renal perfusion and results in acute renal failure. Monitoring kidney function and fluid balance is crucial in managing this complication.
A nurse is assessing a postpartum patient who is showing signs of hypovolemic shock, including hypotension, tachycardia, and decreased consciousness. Which of the following interventions should be prioritized?
A. Provide a high-fiber diet to promote bowel function
B. Initiate intravenous fluid resuscitation
C. Administer analgesics to relieve pain
D. Monitor urine output closely without further action
B. Initiate intravenous fluid resuscitation
Rationale: The priority intervention for hypovolemic shock is intravenous fluid resuscitation to restore blood volume and improve perfusion to vital organs, which is essential in stabilizing the patient.
A postpartum patient is found to have a hematoma in the perineal area. Which of the following interventions should the nurse anticipate as necessary for this condition?
A. Immediate application of a perineal pressure dressing
B. Incision of the skin bulge to evacuate trapped blood
C. Manual removal of the placenta
D. Administration of a uterotonic agent
B. Incision of the skin bulge to evacuate trapped blood
Rationale: Hematomas may require surgical intervention, including incision of the skin bulge to evacuate trapped blood, especially if the patient is experiencing significant pain or difficulty voiding.
A nurse is caring for a postpartum patient who is experiencing slow, steady blood loss with a firm uterus. The bleeding is bright red and without clots. What should the nurse suspect as the most likely cause of hemorrhage?
A. Retained placental fragments
B. Uterine atony
C. Hematoma formation
D. Lacerations of the genital tract
D. Lacerations of the genital tract
Rationale: Bright red bleeding with a firm uterus often indicates trauma, such as lacerations of the genital tract. The absence of clots and firmness of the uterus differentiate this from uterine atony or retained placenta.
A nurse observes a patient with uterine atony and is concerned about ongoing bleeding. Which of the following is the most important initial action in managing this condition?
A. Administer a blood transfusion
B. Prepare the patient for a hysterectomy
C. Massage the uterus to promote contraction
D. Insert a urinary catheter for monitoring urine output
C. Massage the uterus to promote contraction
Rationale: Uterine massage is the first-line intervention for uterine atony, as it helps stimulate uterine contractions and control bleeding. Immediate action can prevent further complications like hypovolemic shock.
A postpartum patient is exhibiting signs of a coagulopathy after delivery, including petechiae and oozing at venipuncture sites. Which of the following laboratory tests would be most appropriate for confirming a coagulopathy as the cause of postpartum hemorrhage?
A. Platelet count and prothrombin time (PT)
B. Hemoglobin and hematocrit
C. Urine culture and sensitivity
D. Blood glucose and liver function tests
A. Platelet count and prothrombin time (PT)
Rationale: A platelet count and prothrombin time (PT) are key tests in diagnosing a coagulopathy, which could be the underlying cause of postpartum hemorrhage in a patient exhibiting signs like petechiae and oozing at venipuncture sites.
A postpartum nurse assesses a patient and finds a boggy uterus and increased bleeding despite no visible lacerations. The nurse suspects retained placental fragments. Which of the following is the most likely sign of this condition?
A. Soft, boggy uterus with dark red bleeding and clots
B. Firm uterus with steady bright red bleeding
C. Firm uterus with a steady stream of dark red blood
D. Boggy uterus with bright red bleeding and no clots
A. Soft, boggy uterus with dark red bleeding and clots
Rationale: Retained placental fragments typically present with a soft, boggy uterus, dark red bleeding, and the presence of blood clots. A careful inspection of the placenta is necessary to confirm this diagnosis.
A nurse is caring for a postpartum patient who is experiencing excessive bleeding. Which of the following actions is most important for the nurse to take before initiating manual fundal massage to improve uterine tone?
A. Assess the patient’s pain level and provide analgesia
B. Position the patient in a lateral position
C. Place one hand over the symphysis pubis to anchor the uterus
D. Administer a uterotonic medication
C. Place one hand over the symphysis pubis to anchor the uterus
Rationale: Before performing manual fundal massage, it is essential to place one hand over the symphysis pubis to anchor the uterus, preventing uterine inversion during the procedure.
A nurse is preparing for the management of postpartum hemorrhage (PPH). Which of the following is a key aspect of the nurse’s role in managing this complication?
A. Managing blood transfusion independently
B. Being the first to recognize and respond to excessive blood loss
C. Performing surgical interventions for hemorrhage control
D. Administering general anesthesia
B. Being the first to recognize and respond to excessive blood loss
Rationale: Nurses play a crucial role in the early recognition and response to excessive postpartum bleeding, ensuring prompt intervention and coordination of further treatments by the healthcare team.
A postpartum patient requires a hysterectomy after failing second-line treatments for excessive bleeding. The nurse is aware of the risks of peripartum hysterectomy. Which of the following complications is most associated with this procedure?
A. Increased risk of renal failure, hepatic failure, and respiratory distress syndrome
B. Increased risk of endometriosis
C. Decreased risk of septicemia
D. Increased risk of thromboembolism
A. Increased risk of renal failure, hepatic failure, and respiratory distress syndrome
Rationale: Peripartum hysterectomy, a lifesaving procedure, carries significant risks, including renal failure, hepatic failure, respiratory distress syndrome, coagulopathies, septicemia, and tissue hypoxia.
A postpartum nurse is preparing for potential blood product transfusion due to excessive bleeding. Which of the following laboratory tests is most important to obtain before initiating the transfusion?
A. Complete blood count (CBC), type and cross-match, and coagulation studies
B. Hemoglobin and hematocrit levels
C. Blood glucose and renal function tests
D. Liver function tests
A. Complete blood count (CBC), type and cross-match, and coagulation studies
Rationale: A CBC, type and cross-match, and coagulation studies are critical to assess the patient’s blood volume and clotting status, ensuring compatibility and readiness for transfusion.
A nurse is caring for a postpartum patient who has excessive bleeding and has reached a blood loss of 1,800 mL. What is the most appropriate next step for the nurse to take?
A. Begin intravenous fluid resuscitation and administer uterotonic agents
B. Initiate a hysterectomy procedure
C. Continue monitoring without any interventions
D. Administer high-dose antibiotics
A. Begin intravenous fluid resuscitation and administer uterotonic agents
Rationale: Once bleeding reaches 1,500 to 2,000 mL, intravenous fluid resuscitation and uterotonic medications should be initiated promptly to manage the bleeding.
A postpartum patient is experiencing excessive bleeding despite initial management steps for uterine atony. Which of the following interventions would the nurse expect as a second-line treatment?
A. Manual fundal massage
B. Administration of uterotonic medications
C. Blood transfusion
D. Uterine compression sutures
D. Uterine compression sutures
Rationale: Uterine compression sutures are a second-line treatment for uterine atony when initial interventions like fundal massage and uterotonic medications fail to control the bleeding.
A nurse is caring for a postpartum patient with uterine atony and excessive bleeding. Which of the following is the first action the nurse should take to manage uterine atony?
A. Administer oxytocin intravenously
B. Prepare for a hysterectomy
C. Administer a blood transfusion
D. Perform a fundal massage after anchoring the uterus
D. Perform a fundal massage after anchoring the uterus
Rationale: The priority intervention for uterine atony is fundal massage, which should be performed after anchoring the uterus with one hand over the symphysis pubis to prevent uterine inversion.
A postpartum nurse is caring for a patient receiving misoprostol (Cytotec) for uterine atony. What should the nurse be aware of when administering this medication?
A. Misoprostol is FDA-approved for postpartum hemorrhage but requires careful monitoring of respiratory status.
B. Misoprostol should only be administered via intravenous injection and never via rectal route.
C. The medication may cause hypotension, so the nurse should monitor the patient’s blood pressure frequently.
D. The nurse should be prepared for immediate surgery if the bleeding does not stop after administering the medication.
C. The medication may cause hypotension, so the nurse should monitor the patient’s blood pressure frequently.
Rationale: Misoprostol can cause hypotension, and the nurse should monitor the patient’s blood pressure frequently during administration to prevent complications.
The nurse is caring for a postpartum patient who is receiving oxytocin (Pitocin) to manage postpartum hemorrhage. Which of the following is a critical component of the nurse’s role in administering this medication?
A. Administering the medication via IV bolus
B. Monitoring uterine tone and vital signs every 15 minutes
C. Providing education on the potential for severe uterine hyperstimulation
D. Reassuring the patient that the medication will not cause discomfort
B. Monitoring uterine tone and vital signs every 15 minutes
Rationale: The nurse must monitor uterine tone and vital signs every 15 minutes to assess the effectiveness of oxytocin and ensure the patient’s safety.
A postpartum patient has been given methylergonovine maleate (Methergine) for uterine atony. Which of the following symptoms should the nurse promptly report to the healthcare provider?
A. Nausea and vomiting
B. Hypotension and dizziness
C. Chest pain
D. Elevated temperature
C. Chest pain
Rationale: Chest pain should be promptly reported as it could indicate serious adverse effects such as myocardial ischemia or cardiovascular complications.
A nurse is caring for a postpartum patient receiving prostaglandin (PGF2α), carboprost (Hemabate) for uterine atony. Which of the following adverse effects should the nurse monitor for most closely?
A. Fever, chills, headache, and vomiting
B. Nausea, vomiting, diarrhea, and flushing
C. Hypertension, palpitations, and seizures
D. Hypotension, dizziness, and chest pain
B. Nausea, vomiting, diarrhea, and flushing
Rationale: Prostaglandin (PGF2α), carboprost (Hemabate) commonly causes nausea, vomiting, diarrhea, flushing, and bronchospasm, so the nurse should monitor for these symptoms.
A postpartum patient is receiving methylergonovine maleate (Methergine) to prevent hemorrhage. The nurse notes that the patient’s blood pressure is elevated. What is the nurse’s most appropriate action?
A. Administer an antihypertensive medication
B. Discontinue the methylergonovine maleate and report the finding
C. Continue monitoring the patient without intervention
D. Increase the dosage of methylergonovine maleate
B. Discontinue the methylergonovine maleate and report the finding
Rationale: Methylergonovine maleate is contraindicated in patients with hypertension, and if the patient experiences elevated blood pressure, the medication should be discontinued and the healthcare provider notified.
Which of the following nursing interventions is most appropriate when administering dinoprostone (Prostin E2) to a postpartum patient?
A. Monitor the patient’s blood pressure frequently
B. Monitor for signs of uterine hyperstimulation
C. Assess the patient’s blood glucose levels
D. Monitor for signs of electrolyte imbalances
A. Monitor the patient’s blood pressure frequently
Rationale: Hypotension is a frequent side effect of dinoprostone, so the nurse should monitor blood pressure frequently during administration.
A nurse is administering misoprostol (Cytotec) for postpartum hemorrhage. Which of the following is a key contraindication for this medication?
A. Active cardiovascular disease
B. History of asthma
C. Pregnancy under 20 weeks
D. Sepsis
A. Active cardiovascular disease
Rationale: Misoprostol is contraindicated in patients with active cardiovascular disease and should be used cautiously in those with asthma.
A nurse is administering oxytocin (Pitocin) to a postpartum patient to control bleeding. What is the most important nursing implication when administering this medication?
A. Monitor for signs of uterine hyperstimulation and assess uterine tone regularly
B. Administer the medication via a subcutaneous injection
C. Assess for signs of hypotension as a common side effect
D. Monitor the patient for signs of tachycardia as a frequent side effect
A. Monitor for signs of uterine hyperstimulation and assess uterine tone regularly
Rationale: Oxytocin should be carefully monitored for uterine hyperstimulation, and uterine tone must be regularly assessed to ensure effective control of bleeding and to prevent adverse effects.
Which of the following describes the ideal time for removal of the JADA system following postpartum hemorrhage treatment?
A. 2 hours after insertion
B. 15 minutes after insertion
C. 30 minutes to 1 hour after insertion
D. 24 hours after insertion
C. 30 minutes to 1 hour after insertion
Rationale: The JADA system should be left in place for 30 minutes to 1 hour, after which it should be removed and the patient should be observed for any further bleeding.
A patient with uterine atony is undergoing treatment with the JADA system. How soon after placement should the nurse expect to see uterine collapse?
A. Within 1 minute
B. Within 5 minutes
C. Within 10 minutes
D. Within 30 minutes
A. Within 1 minute
Rationale: Studies show that uterine collapse happens within 1 minute after the JADA system is placed, which helps control bleeding rapidly.
What is a significant drawback of the JADA system in comparison to other uterine tamponade devices such as the Bakri balloon?
A. The JADA system requires a highly skilled surgeon for insertion
B. The JADA system is less effective in controlling bleeding
C. The JADA system requires longer post-procedure monitoring
D. The JADA system is more expensive than the Bakri balloon
D. The JADA system is more expensive than the Bakri balloon
Rationale: The JADA system is more expensive than the Bakri balloon, which may be a consideration for healthcare providers when choosing an appropriate intervention.
The nurse is explaining the JADA system to a new nurse. Which statement by the new nurse indicates that additional teaching is required?
A. “The JADA system uses a vacuum to help the uterus contract naturally.”
B. “The device should be inserted past the internal os of the cervix.”
C. “The device will be left in place for several hours to monitor bleeding.”
D. “Suction is attached to the device to remove blood and keep the cervical seal intact.”
C. “The device will be left in place for several hours to monitor bleeding.”
Rationale: The device should only be left in place for 30 minutes to 1 hour, not several hours. If the new nurse states otherwise, further teaching is necessary.
A postpartum patient has the JADA system in place for uterine atony. The nurse notes that the device has been in place for 1 hour. What is the nurse’s next best action?
A. Remove the device and prepare for potential surgery
B. Leave the device in place for an additional 30 minutes
C. Increase the suction level to improve uterine contraction
D. Observe the patient for further bleeding after removing the device
D. Observe the patient for further bleeding after removing the device
Rationale: The device should be removed after 30 minutes to 1 hour, and the nurse should observe the patient for any further bleeding to assess the effectiveness of the intervention.
Which of the following is the most important post-procedure nursing action after the removal of the JADA system?
A. Administer pain medication as prescribed
B. Observe for any further bleeding
C. Prepare the patient for a hysterectomy if bleeding persists
D. Immediately perform a bimanual exam to assess for uterine atony
B. Observe for any further bleeding
Rationale: After removal of the JADA system, it is essential to observe the patient for any further bleeding to ensure effective control and identify any complications.
A nurse is educating a postpartum patient about the JADA system. Which of the following statements should the nurse include in the teaching?
A. “The device will be left in place for up to 4 hours to monitor for bleeding.”
B. “The device works by applying pressure to the uterine wall to stop bleeding.”
C. “The device will be attached to wall suction to remove blood and maintain cervical seal.”
D. “You should expect to experience severe cramping for the entire duration of the device use.”
C. “The device will be attached to wall suction to remove blood and maintain cervical seal.”
Rationale: The JADA system is attached to wall suction to remove blood while maintaining the cervical seal, promoting uterine contraction and bleeding control.
Which of the following is a key benefit of the JADA system compared to the Bakri balloon?
A. It is significantly less expensive than the Bakri balloon
B. It requires more invasive procedures for insertion
C. It uses a low-level vacuum to promote natural uterine contraction
D. It requires no post-procedure monitoring
C. It uses a low-level vacuum to promote natural uterine contraction
Rationale: The JADA system uses a low-level vacuum to help the uterus contract naturally, offering a key advantage in controlling bleeding.
A nurse is preparing to use the JADA system for a postpartum patient experiencing uterine atony. What is the most important consideration when using this system?
A. Ensure the patient has a history of cardiovascular disease
B. Remove the device after 15 minutes
C. Administer oxytocin before inserting the device
D. Place the device just past the internal os of the cervix
D. Place the device just past the internal os of the cervix
Rationale: The JADA system is inserted just past the internal os of the cervix to help control bleeding and facilitate uterine contraction.
A nurse is assessing a postpartum patient who had a precipitous birth. Which of the following is the nurse’s priority assessment to prevent hemorrhage due to retained placental tissue?
A. Assess for a distended bladder
B. Inspect the placenta for completeness after expulsion
C. Monitor for uterine hyperstimulation
D. Perform a pelvic examination for signs of infection
B. Inspect the placenta for completeness after expulsion
Rationale: After expulsion, the placenta must be thoroughly inspected for completeness to rule out retained placental fragments, which could result in hemorrhage if not addressed.
A nurse is caring for a postpartum patient who has developed a hematoma following a forceps delivery. Which of the following is the most likely early sign of this complication?
A. Rapidly increasing blood pressure with fainting
B. Severe abdominal pain and fever
C. Pain at the site of the hematoma and vital signs changes disproportionate to blood loss
D. Sudden onset of uterine contractions with minimal bleeding
C. Pain at the site of the hematoma and vital signs changes disproportionate to blood loss
Rationale: Hematomas often present with pain at the site and changes in vital signs that are disproportionate to the amount of visible blood loss.
A nurse is assessing a postpartum patient who has had a previous cesarean section. Which complication is this patient at higher risk for during labor?
A. Placental abruption
B. Uterine rupture
C. Hematoma formation
D. Cervical lacerations
B. Uterine rupture
Rationale: Women with a previous cesarean section are at higher risk for uterine rupture, especially during labor, due to the potential disruption of the uterine wall.
A nurse is caring for a patient who is experiencing vaginal bleeding following a forceps delivery. The uterus is contracted, but the patient continues to have bright red blood trickling from the vagina. Which of the following is the most likely cause of this bleeding?
A. Retained placental tissue
B. Uterine atony
C. Cervical lacerations
D. Endometriosis
C. Cervical lacerations
Rationale: Bright red blood trickling from the vagina with a contracted uterus is most often indicative of cervical lacerations, commonly associated with forceps deliveries.
A nurse is caring for a postpartum patient who had a vigorous labor and is at risk for trauma. Which of the following interventions can help prevent trauma during delivery?
A. Administer oxytocin for strong uterine contractions
B. Perform controlled delivery with gentle manipulation
C. Use forceps during delivery to expedite the process
D. Allow the patient to bear down before the cervix is fully dilated
B. Perform controlled delivery with gentle manipulation
Rationale: Controlled delivery with gentle manipulation and appropriate inspection and repair of lacerations or episiotomy can help prevent trauma, such as lacerations and hematomas.
A postpartum patient has been diagnosed with a coagulation disorder after presenting with prolonged bleeding. The nurse is preparing to administer clotting factor replacement therapy. What should the nurse monitor closely in this patient?
A. Respiratory rate
B. Liver function tests
C. Urine output for signs of fluid overload
D. Neurological status for signs of clot formation
D. Neurological status for signs of clot formation
Rationale: Clotting factor replacement therapy increases the risk of thrombosis, so the nurse should monitor neurological status for signs of clot formation, such as confusion or sudden weakness, which may indicate a thrombotic event.
A nurse is assessing a postpartum patient for signs of disseminated intravascular coagulation (DIC). Which of the following is a key characteristic of DIC?
A. Decreased fibrinogen levels and prolonged prothrombin time
B. Increased platelet count and normal bleeding time
C. Localized bleeding from a single site
D. Elevated hemoglobin and hematocrit
A. Decreased fibrinogen levels and prolonged prothrombin time
Rationale: In DIC, coagulation factors are consumed rapidly, leading to decreased fibrinogen levels, prolonged prothrombin time, and abnormal clotting tests. It can cause widespread bleeding and clotting problems.
A postpartum patient has a prolonged bleeding time, decreased platelet count, and increased fibrin degradation products. Which of the following conditions is most likely contributing to her bleeding?
A. Uterine atony
B. Thrombotic thrombocytopenic purpura (TTP)
C. Retained placental tissue
D. Placenta previa
B. Thrombotic thrombocytopenic purpura (TTP)
Rationale: Thrombotic thrombocytopenic purpura (TTP) is a condition associated with a decreased platelet count, prolonged bleeding time, and fibrin degradation products. This can result in abnormal bleeding during the postpartum period.
A postpartum patient presents with persistent bleeding and no identifiable cause. The nurse suspects a coagulation disorder. Which diagnostic test is most appropriate to confirm the diagnosis?
A. Complete blood count (CBC)
B. Ultrasound of the uterus
C. Blood glucose levels
D. Coagulation studies, including prothrombin time and fibrinogen levels
D. Coagulation studies, including prothrombin time and fibrinogen levels
Rationale: Coagulation studies are essential to diagnose coagulation disorders in postpartum hemorrhage. These studies include prothrombin time, fibrinogen levels, and other clotting factors that can confirm a bleeding disorder.
A nurse is caring for a postpartum patient with a known history of von Willebrand disease. Which of the following should the nurse prioritize to prevent postpartum hemorrhage (PPH)?
A. Administering oxytocin to stimulate uterine contractions
B. Administering anticoagulants to prevent thrombosis
C. Observing for signs of bleeding despite normal uterine tone
D. Monitoring the patient for signs of thrombotic complications
C. Observing for signs of bleeding despite normal uterine tone
Rationale: Women with von Willebrand disease are at risk for bleeding disorders, and while uterine contractions are important, the nurse should be vigilant for signs of bleeding that may occur even with a well-contracted uterus.
Which of the following is a key disadvantage of using vacuum extraction in operative vaginal births?
A. Higher risk of maternal pelvic floor trauma
B. Higher failure rate compared to forceps-assisted delivery
C. Decreased likelihood of successful delivery
D. Increased neonatal risk of scalp and facial trauma
D. Increased neonatal risk of scalp and facial trauma
Rationale: One of the key disadvantages of vacuum extraction is the increased risk of neonatal trauma, including scalp lacerations and cephalohematoma.
Which of the following is an appropriate preventive measure to reduce the need for forceps or vacuum-assisted delivery?
A. Administering a general anesthetic
B. Encouraging frequent ambulation and bladder emptying during labor
C. Limiting patient fluid intake during labor
D. Administering pitocin to augment labor
B. Encouraging frequent ambulation and bladder emptying during labor
Rationale: Encouraging ambulation and regular bladder emptying helps optimize pelvic space and positioning, potentially preventing the need for operative interventions like forceps or vacuum-assisted deliveries.
A nurse is assisting in a vacuum-assisted delivery. The doctor applies traction, and the fetal head begins to emerge. What should the nurse do next to ensure the success of the procedure?
A. Apply gentle traction with the doctor to facilitate delivery
B. Withhold additional traction until the fetal head is fully delivered
C. Reposition the patient to increase pelvic space
D. Monitor the maternal vital signs closely to assess for shock
A. Apply gentle traction with the doctor to facilitate delivery
Rationale: Gentle and steady traction is necessary during a vacuum-assisted delivery to guide the fetal head out while avoiding excessive force, which could lead to neonatal injury.
A postpartum patient who had a vacuum-assisted delivery is being monitored for potential complications. Which finding would indicate a possible cephalohematoma in the neonate?
A. Soft swelling on the neonate’s head that resolves within 24 hours
B. Bruising on the neonate’s face and scalp
C. Increased head circumference and a palpable mass on the skull
D. Fluctuating fetal heart rate
C. Increased head circumference and a palpable mass on the skull
Rationale: Cephalohematoma is a collection of blood between the skull and the periosteum, often seen after a vacuum-assisted delivery. The head may show increased circumference and a palpable mass.
A nurse is educating a laboring patient about the potential use of forceps or a vacuum extractor. Which of the following should the nurse include in the discussion?
A. These procedures are always performed without the patient’s consent
B. Both forceps and vacuum extractions pose a risk of fetal skull fractures
C. The primary risk of these procedures is maternal infection
D. Both forceps and vacuum extractions are rare in current obstetric practice
D. Both forceps and vacuum extractions are rare in current obstetric practice
Rationale: The use of forceps and vacuum extractions has declined in modern obstetric practice, but they are still used when necessary, and their risks need to be carefully explained to the patient.
Which of the following is a primary advantage of using forceps over vacuum extraction in assisted deliveries?
A. Lower maternal pelvic floor injury rates
B. Reduced neonatal trauma
C. Higher success rate of delivery
D. Increased risk of maternal lacerations
C. Higher success rate of delivery
Rationale: Forceps have a lower failure rate compared to vacuum extraction, making them more reliable for assisting in deliveries when indicated. However, they do carry a higher risk for maternal pelvic floor injuries.
A patient who underwent a forceps-assisted delivery is at risk for which maternal complication?
A. Placenta previa
B. Lacerations of the cervix, vagina, or perineum
C. Fetal skull fracture
D. Postpartum depression
B. Lacerations of the cervix, vagina, or perineum
Rationale: Maternal complications from forceps-assisted delivery include lacerations of the cervix, vagina, or perineum, as well as hematoma, hemorrhage, and infection.
During a vacuum-assisted birth, the nurse notices the fetal heart rate (FHR) is showing signs of distress. Which of the following is the most appropriate immediate action?
A. Continue with the vacuum extraction until delivery is complete
B. Discontinue the procedure and prepare for a cesarean section
C. Apply more traction to expedite the delivery
D. Reposition the patient and continue monitoring the FHR
B. Discontinue the procedure and prepare for a cesarean section
Rationale: Fetal distress during a vacuum-assisted birth requires discontinuation of the procedure, reassessment, and possible preparation for cesarean delivery to ensure fetal safety.
A nurse is caring for a postpartum patient who underwent a vacuum-assisted delivery. Which complication should the nurse monitor for in the neonate after the procedure?
A. Cephalohematoma
B. Fractured clavicle
C. Hypoglycemia
D. Respiratory distress syndrome
A. Cephalohematoma
Rationale: Vacuum-assisted deliveries can cause neonatal trauma, including cephalohematoma (a collection of blood between the skull and periosteum), which requires monitoring.
A nurse is preparing for a vacuum-assisted delivery. Which of the following criteria must be met for the vacuum extractor to be safely applied?
A. The maternal cervix is dilated to 6 cm
B. The fetal head is at a +2 station
C. The maternal pelvis is not adequate for birth
D. The membranes are ruptured and the cervix is completely dilated
D. The membranes are ruptured and the cervix is completely dilated
Rationale: For the vacuum extractor to be applied, the cervix must be fully dilated, the membranes ruptured, and the fetus engaged in the vertex position. These criteria ensure safe use of the instrument.
A nurse is caring for a patient in active labor who has been pushing for over three hours with minimal fetal descent. The fetal heart rate is reassuring, and contractions are occurring every 2-3 minutes. The healthcare provider diagnoses labor dystocia. Which intervention should the nurse anticipate?
A) Applying fundal pressure to assist with fetal descent
B) Preparing for an emergency cesarean section
C) Administering oxytocin to strengthen contractions
D) Performing McRoberts maneuver and suprapubic pressure
C) Administering oxytocin to strengthen contractions
Rationale: Labor dystocia is characterized by abnormally slow or prolonged labor due to ineffective uterine contractions, fetal malposition, or cephalopelvic disproportion (CPD). If contractions are inadequate, oxytocin is often administered to improve labor progression. Fundal pressure is contraindicated, especially in cases of CPD, as it increases the risk of uterine rupture. Cesarean section may be necessary if labor does not progress despite interventions, but it is not the first-line response. McRoberts maneuver and suprapubic pressure are specific for shoulder dystocia, not labor dystocia.
