Quiz #2 Review Question Flashcards
Tocolytic therapy
- stop contractions. Use for preterm patients i.e: indomethacin, nifedipine procardi
Oxytoxic meds
(oxytocin, hemabate, methergine): for hemorrhage
baby position for back labor: posterior
When “back labor” is most likely to occur
When fetal position is occiput posterior and baby’s head is pressing on structures of back.**
Walking in less than 24 hrs postpartum. Expect to find? Fundus at umbilicus, everyday
post 1 sonometer down (-1, -2, -3), tone is firm midline.
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
A. Encourage the client to perform Kegel exercises.
B. Encourage the client to move to the left lateral position.
C. Ask the client to rate her pain.
D. Encourage the client to empty bladder by voiding
D. Encourage the client to empty bladder by voiding
Encouraging the client to empty the bladder by voiding is essential, as a full bladder can displace the uterus and contribute to uterine atony.
A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client’s vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?
A. Give the client a new pad and check her in 30 minutes.
B. Assess the fundus and massage it if it’s boggy.
C. Call the physician for a methylergonovine order.
D. Ask the client to get out of bed and try to urinate.
B. Assess the fundus and massage it if it’s boggy.
A nurse is caring for a client who is 12hr postpartum. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?
A. Expressions of excitement
B. Lack of appetite
C. Eagerness to learn newborn care skills
D. Focus on the family unit and its members
A. Expressions of excitement
Expressions of excitement are an expected finding during the taking-in phase of maternal postpartum adjustment. This is the time of reflection for the woman because, within the 2 to 3-day period, the woman is passive and dependent on her healthcare provider or support person with some of the daily tasks and decision-making. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role.
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?
A. Assist the family to identify prior use of positive coping skills in family crises.
B. Ask the client if she has considered harming her newborn.
C. Anticipate a prescription by the provider for an antidepressant.
D. Reinforce postpartum and newborn care discharge teaching.
B. Ask the client if she has considered harming her newborn.
This is the priority action by the nurse. The client’s symptoms are indicative of postpartum depression, and the nurse must assess if she has considered harming her newborn. This assessment is crucial for the safety and well-being of both the mother and the baby.
Which of the following women should receive RhoGAM postpartum?
A. Nonsensitized Rh-negative mother with a Rh-negative newborn
B. Nonsensitized Rh-negative mother with a Rh-positive newborn
C. Sensitized Rh-negative mother with a Rh-positive newborn
D. Sensitized Rh-negative mother with a Rh-negative newborn
B. Nonsensitized Rh-negative mother with a Rh-positive newborn
A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of lactated Ringers with 25 units of oxytocin infusing & has large rubra lochia. Vital signs include BP: 146/94, Pulse: 80/min & RR: 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
a. Methylergonovine 0.2 mg IM now
b. Insert an indwelling urinary catheter
c. Administer oxygen by nonrebreather mask at 5L/min
d. Obtain laboratory study of prothrombin & partial thromboplastin time.
a. Methylergonovine 0.2 mg IM now (methergine is oxytocic)
Methylergonovine is contraindicated with a blood pressure greater than 140/90
A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?
A. Place 3 to 4 pillows under the client’s knees when resting in bed.
B. Massage the client’s posterior lower legs.
C. Have the client ambulate.
D. Apply warm, moist heat to the client’s lower extremities.
C. Have the client ambulate.
Having the client ambulate helps prevent venous stasis and reduces the risk of thromboembolic events.
A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?
A. Pelvic pain
B. Hematuria
C. A localized area of breast tenderness
D. A moderate amount of dark red lochia with a foul odor
A. Pelvic pain
Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.
Pt delivered 10 days ago, pain redness left calf. Tell to see HCP immediately. What
else?
Elevate
When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:
A) massage the fundus.
B) administer Methergine, 0.2 mg PO, that has been ordered prn.
C) assist the woman to empty her bladder.
D) recognize this as an expected finding during the first 24 hours following birth.
C) assist the woman to empty her bladder.
Rationale:
A firm fundus should not be massaged since massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding, and an action is required.
A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?
Apply an ice pack to the affected area.
Offer a warm sitz bath.
Provide a squeeze bottle of antiseptic solution.
Place a hot pack to the perineum.
Apply an ice pack to the affected area.
Apply an ice pack to the affected area. Ice packs are recommended during the first 24 hours after birth to decrease swelling and help with pain.
