NCLEX Practice Questions — Set 41
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
The health care provider has performed an amniotomy on a laboring client. Which of the following details must be included in the documentation of this procedure?
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Correct answer: A. All of the above
The time of rupture; color, odor, amount, and clarity of amniotic fluid; and FHR and pattern before and after the procedure are all information that must be documented on the client’s record. There is only one size for an amnio-hook.
Following an epidural and placement of internal monitors, a client’s labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1� minutes. The uterine resting tone is greater than 20 mm mercury with an abnormal fetal heart rate and pattern. Which of the following actions should the nurse take first?
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Correct answer: D. Turn off the oxytocin infusion.
The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin, should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the health care provider.
A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include:
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Correct answer: D. Reposition patient, apply oxygen, and increase IV fluids.
Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the patient, oxygen, and IV fluids. A sterile vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not indicate an imminent birth.
A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?
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Correct answer: C. Turn the client to her left side.
Accelerations that are episodic and occur during fetal movement demonstrate fetal well-being. Turning the client to the left side, applying oxygen by face mask and notifying the health care provider are interventions used for late and variable decelerations indicating the fetus is not tolerating the induction process well.
As a nurse begins her shift on the obstetrical unit, there are several new admissions. The client with which of the following conditions would be a candidate for induction?
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Correct answer: C. Preeclampsia.
The client with preeclampsia would be a candidate for the induction process because ending the pregnancy is the only way to cure preeclampsia. A client with active herpes would be a candidate for a cesarean section to prevent the fetus from contracting the virus while passing through the birth canal. The woman with a face presentation will not be able to give birth vaginally due to the extended position of the neck. The client whose fetus exhibits late decelerations without oxytocin would be at greater risk for fetal distress with use of this drug. Late decelerations indicate the fetus does not have enough placental reserves to remain oxygenated during the entire contraction. This client may require a cesarean section.
A nurse and an LPN are working in the labor and birth unit. Of the following assessments and interventions that must be done immediately, which should the nurse assign to the LPN?
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Correct answer: C. Perform a straight catheterization for protein analysis.
The straight catheterization is within the scope of practice of a licensed practical nurse. An initial or continuing assessment is the responsibility of the registered nurse. Assessment must be complete before increasing the IV rate of oxytocin. The assessment and the increase in oxytocin rate are responsibilities for the nurse. The RN, not the LPN, recovers clients who have had surgery because frequent assessments are needed.
A nurse and a nursing assistant are caring for clients in a labor and birth unit. Which task should the registered nurse assign to the nursing assistant?
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Correct answer: D. Remove a fetal monitor and assist a client to the bathroom.
Removing a fetal monitor from a client and assisting her to the bathroom are within the realm of practice of a nursing assistant. Performing a fundal check is an assessment, which is a responsibility of a registered nurse. A nursing assistant is not permitted to administer medication by any route. Education is also part of the professional nursing role. Although a nursing assistant can assist a mother with bottle-feeding, the formal client education must be completed and validated by the nurse.
A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks only Mandarin and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching birth?
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Correct answer: C. The fetal monitor strip shows early decelerations.
When the fetal head is compressed, early decelerations are seen as a vagal response occurs and the fetal heart rate decelerates and inversely mirrors the contraction. This response commonly occurs when the client is 9 to 10 cm dilated or pushing. If communication cannot be facilitated, early decelerations are one indicator that birth may be approaching. Late decelerations may occur at this time but indicate uteroplacental insufficiency rather than imminent birth. At any time during the labor process, the client may communicate with her family in her native language. The client’s facial expressions may change at any point during labor and cannot be used as an indicator of imminent birth.
A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which of the following signs and symptoms?
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Correct answer: C. All of the above
With abruptio placentae, bleeding may occur vaginally, may be obstructed by the fetal head, or it may be hidden behind a portion of the placenta. Abdominal rigidity occurs, particularly with a concealed hemorrhage because the girth and fundal height increase. Abdominal pain is one of the classic symptoms of abruption. The pain may be intermittent, as in labor contractions, or continuous. The placenta with abruption is not larger than a normal placenta and the bleeding does not end spontaneously.
A multigravid client is in active labor with twins at 38 weeks’ gestation. The nurse should monitor the client closely for symptoms of which of the following?
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Correct answer: D. Preeclampsia.
Clients who are pregnant with two (or more) fetuses are at greater risk for preeclampsia, hydramnios, placenta previa, preterm labor, and anemia. During childbirth, occasionally the placenta of the second twin separates before that twin is born, causing profound bleeding. Urinary tract infections and chorioamnionitis are not more common in clients with multifetal gestation compared with women with single-fetus pregnancies. Although multiparous women frequently give birth more quickly than a nullipara does, precipitous birth is not more common with twin gestations.
A 39-year-old multigravid client at 39 weeks’ gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?
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Correct answer: A. Remain in a side-lying position with the head elevated.
The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler’s position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted. Although breathing slowly during a contraction may assist with oxygenation, it would have no effect on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of discomfort and anxiety. Effective intrapartum pain relief with analgesia and epidural anesthesia may reduce cardiac workload as much as 20%. Local anesthetics are effective only during the second stage of labor.
When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently?
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Correct answer: B. Tachycardia.
Assessing for signs and symptoms associated with cardiac decompensation is the priority. Class III heart disease during pregnancy has a 25% to 50% mortality. These clients are markedly compromised, with marked limitation of physical activity. They frequently experience fatigue, palpitations, dyspnea, or anginal pain. A pulse rate greater than 100 bpm or a respiratory rate greater than 25 breaths/min may indicate cardiac decompensation that could result in cardiac arrest. Additional symptoms include dyspnea, peripheral edema, orthopnea, tachypnea, rales, and hemoptysis.
A multigravid client in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should anticipate that the primary health care provider most likely prescribe which of the following medications?
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Correct answer: A. Antibiotics.
Clients who have been diagnosed with class II heart disease and prosthetic valve replacement are most likely to have a prescription for antibiotic medications to prevent the development of bacterial endocarditis and bacteremia. Clients with valvular heart disease have a high susceptibility to subacute bacterial endocarditis. Anticoagulant therapy is usually discontinued during labor and birth because of the potential for hemorrhage. Diuretic medications are generally not prescribed for clients with class I or class II heart disease. Diuretics usually are not necessary and may result in potassium depletion. Folic acid supplements are usually prescribed for clients with megaloblastic anemia. Folic acid is also included in many prenatal vitamins and can help to prevent neural tube defects in the fetus.
A multigravid client at 39 weeks’ gestation diagnosed with insulin-dependent diabetes is admitted for induction of labor with oxytocin. Which of the following should the nurse include in the teaching plan as a possible disadvantage of this procedure?
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Correct answer: B. Neonatal jaundice.
One of the potential disadvantages of oxytocin induction is neonatal jaundice or hyperbilirubinemia. Oxytocin decreases the elimination of bilirubin from the neonate. Other adverse effects include maternal hypertension and frontal headache, which disappear when the drug is discontinued. The drug has antidiuretic properties that can lead to maternal water intoxication. Dangerous effects of this powerful drug include uterine hyperstimulation or tetanic contractions, which can result in abruptio placentae and uterine rupture. Urinary frequency, maternal hypoglycemia, and preterm birth are not associated with oxytocin administration. Ultrasound procedures are used to estimate gestational age to prevent preterm birth. Clients with diabetes commonly give birth before term because the placenta begins to deteriorate, which can result in stillbirth.
A primigravida is experiencing a prolonged second stage of labor with a fetus suspected of weighing over 4 kg. Which of the following interventions is most important?
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Correct answer: B. Performing the McRoberts maneuver.
A prolonged second stage of labor with a large fetus could indicate a shoulder dystocia at birth. Immediate nursing actions for a shoulder dystocia include suprapubic pressure and the McRoberts maneuver. If after interventions for vaginal birth with a shoulder dystocia fail, an emergency cesarean birth may be needed but is not indicated at this time. A vacuum-assisted birth would be contraindicated due to increased risk of shoulder dystocia with a macrosomic infant. An IV fluid bolus may be indicated for fetal distress, but there is not enough information to establish that they are needed at this time.
A multigravid client is receiving oxytocin augmentation. When the client’s cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which of the following actions should the nurse do first?
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Correct answer: C. Monitor the fetal heart rate continuously.
A common sign of fetal distress related to an inadequate transfer of oxygen to the fetus is meconium-stained fluid. Because the fetus has suffered hypoxia, close fetal heart rate monitoring is necessary. In addition, all clients are monitored continuously after rupture of membranes for fetal distress caused by cord prolapse. If there are increasing signs of fetal distress (eg, late decelerations), the primary health care provider should be notified immediately. A cesarean birth may be performed for fetal distress. Increasing the rate of the oxytocin infusion could lead to further fetal distress. Turning the client to the left side, rather than a knee-chest position, improves placental perfusion. The primary health care provider may wish to determine the extent of cervical dilation to make a decision about whether a cesarean birth is warranted, but continuous fetal heart rate monitoring is essential to determine fetal status.
A multigravid client in active labor at 39 weeks’ gestation has a history of smoking one to two packs of cigarettes daily. For which of the following should the nurse be alert when assessing the client’s neonate?
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Correct answer: A. Low birth weight.
Neonates born to mothers who smoke tend to have lower-than-average birth weights. Neonates born to mothers who smoke also are at higher risk for stillbirth, sudden infant death syndrome, bronchitis, allergies, delayed growth and development, and polycythemia. Maternal smoking is not related to higher neonatal sedation, hyperbilirubinemia, or hypocalcemia. Smoking may cause irritability, not sedation. Hyperbilirubinemia is associated with Rh or ABO incompatibility or the administration of intravenous oxytocin during labor. Approximately 50% of neonates born to mothers with insulin-dependent diabetes experience hypocalcemia during the first 3 days of life.
A primigravid client who has had a prolonged labor but now is completely dilated has received epidural anesthesia. Which of the following should the nurse include in the teaching plan about pushing?
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Correct answer: A. The client should be urged to push with an open glottis.
The client should be urged to push with an open glottis to prevent the Valsalva maneuver. Pushing with a closed glottis increases intrathoracic pressure, preventing venous return. Blood pressure also falls, and cardiac output decreases. Pushing for at least 1 to 3 minutes is too long; prolonged pushing can lead to reduced blood flow and fatigue. Pushing for the duration of the contraction is sufficient. Pushing while holding the breath results in the Valsalva maneuver. Because the client has had an epidural anesthetic, she may not feel the urge to push and may need coaching during the pushing phase.
The primary health care provider determines that outlet forceps are needed to assist in the birth of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse reinforces the primary health care provider’s explanation for using forceps based on the understanding about which of the following concerning the location of the fetal skull?
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Correct answer: B. It is engaged past the inlet.
When the fetal skull is on the perineum with the scalp visible at the perineal floor or vaginal opening, this is considered outlet forceps application. When the head is higher in the pelvis but engaged and its greatest diameter has passed the inlet, the operation is termed midforceps. Midforceps births are not recommended because they are extremely dangerous for the mother and fetus because of the possibility of uterine rupture. If the head is not engaged, at -1 station, this is termed high forceps. High forceps births also are exceedingly dangerous for both the mother and fetus because of the possibility of uterine rupture and are not recommended. Cesarean birth is preferred in these situations. The fetal head at station +2 or lower is termed low forceps.
The primary health care provider prescribes an amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client’s teaching plan about the purpose of this procedure?
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Correct answer: A. To decrease the frequency and severity of variable decelerations.
Oligohydramnios, or a decrease in the volume of amniotic fluid, is associated with variable fetal heart rate decelerations due to cord compression. Maintenance of an adequate amniotic fluid volume during labor provides protective cushioning of the umbilical cord and minimizes cord compression. Cord compression can result in fetal metabolic acidosis, not alkalosis. Amnioinfusion is used to minimize cord compression, not to increase the fetal heart rate accelerations during a contraction. The goal is to maintain the amniotic fluid index at 8 cm. This can be determined by ultrasound
The nurse is admitting a primigravid client at 37 weeks’ gestation who has been diagnosed with preeclampsia to the labor and birth area. Which of the following client care rooms is most appropriate for this client?
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Correct answer: A. A darkened private room as close to the nurses’ station as possible.
A primigravid client diagnosed with preeclampsia has the potential for developing seizures (eclampsia). This client should be in a room with the least amount of stimulation possible to reduce the risk of seizures and as close to the nurses’ station as possible in case the client requires immediate assistance. Bright lighting and sunshine can be a stimulant, possibly increasing the risk of seizures, as can being in a semiprivate room with roommate, visitors, conversation, and noise.
A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, "The baby’s coming!" To help the client remain calm and cooperative during the imminent birth, which of the following responses by the nurse is most appropriate?
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Correct answer: C. "I’ll explain what’s happening to guide you as we go along."
The client is experiencing a precipitous birth. The nurse should remain calm during a precipitous birth. Explaining to the client what is happening as the birth progresses and how she can assist is likely to help her remain calm and cooperative. Maintaining eye contact is also beneficial. Telling the client that she is right and to just relax is inappropriate because the client may not be able to relax because of the strong urge to push the fetus out of the birth canal. Telling the client not to push because she may tear the cervix can instill fear, not cooperation. Saying that the primary health care provider will be there soon may not be an accurate statement and is not reassuring if the client is concerned about the birth.
The nurse is caring for a multigravid client who speaks only a foreign language. As the nurse enters the client’s room, the nurse observes the client squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?
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Correct answer: C. Provide gentle support to the fetal head.
During a precipitous birth, after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent it from coming out. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying downward traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder. Priority should be given to safe birth of the infant over protecting the perineum by massage
During the first hour after a precipitous birth, the nurse should monitor a multiparous client for signs and symptoms of which of the following?
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Correct answer: D. Uterine atony.
Because birth occurs so rapidly and the fetus is propelled quickly through the birth canal, the major complication of a precipitous birth is a boggy fundus, or uterine atony. The neonate should be put to the breast, if the mother permits, to allow for the release of natural oxytocin. In a hospital setting, the primary health care provider will probably prescribe administration of oxytocin. The nurse should gently massage the fundus to ensure that it is firm. There is no relationship between a precipitous birth and postpartum "blues" or intrauterine infection. Postpartum "blues" usually do not occur until about 3 days postpartum, and symptoms of postpartum infection usually occur after the first 24 hours. There is no relationship between a precipitous birth and urinary tract infection even though the birth has been accomplished under clean rather than sterile technique. Symptoms of urinary tract infection typically begin on the first or second postpartum day.
A multigravid client in labor at 38 weeks’ gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely?
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Correct answer: C. Sinusoidal pattern.
The fetal heart rate of a multipara diagnosed with Rh sensitization and probable fetal hydrops and anemia will most likely demonstrate a sinusoidal pattern that resembles a sine wave. It has been hypothesized that this pattern reflects an absence of autonomic nervous control over the fetal heart rate resulting from severe hypoxia. This client will most likely require a cesarean birth to improve the fetal outcome. Early decelerations are associated with head compression; variable decelerations are associated with cord compression; and late decelerations are associated with poor placental perfusion.
The nurse in the labor and birth area receives a telephone call from the emergency room announcing that a multigravid client in active labor is being transferred to the labor area. The client has had no prenatal care. When the client arrives by stretcher, she says, "I think the baby’s coming � Help!" The fetal skull is crowning. The nurse should obtain which of the following information first?
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Correct answer: C. Estimated date of birth.
A priority assessment for the nurse to make is to determine the estimated date of childbirth or probable gestational age of the fetus. If the gestation is less than 37 weeks, the neonatal team should be called to begin resuscitative efforts if needed. Amniotic fluid status is not important at this point, because if the fetal skull is crowning, birth is imminent. Determination of gravida and parity is part of the normal nursing history, but the priority is the status of the fetus and safe birth. Prenatal history is part of the nursing assessment, but this information is not especially relevant until the fetus is safely born and has been given immediate care.
A multiparous client gives birth to dizygotic twins at 37 weeks’ gestation. The twin neonates require additional hospitalization after the client is discharged. In planning the family’s care, an appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following?
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Correct answer: D. Participate in care of the twins as much as possible.
It is important that the parents be allowed to touch, hold, and participate in care of the twins whenever they desire. Ideally, this will be on a daily basis, to promote parent-infant bonding. It is not appropriate to discuss how the couple will cope with twin infants at home until they are ready to take the infants home. They are too overwhelmed at this point and are focused on the well-being of their infants while hospitalized. Having the couple visit the twins to provide care on a 24-hour basis is not warranted. Identifying complications that may occur is not appropriate. If complications arise, the parents should be well informed and given opportunities for discussion related to the care provided.
A primigravid client at 41 weeks’ gestation is admitted to the hospital’s labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which of the following problems should the nurse identify as the priority for the client?
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Correct answer: B. Sleep deprivation.
Birth trauma and prolonged ruptured membranes make risk for infection the priority problem for this client. Infection can be a serious postpartum complication. Although the client may be fatigued, she should not be experiencing activity intolerance. Clients with heart disease may experience activity intolerance due to excessive cardiac workload. Although the client may be experiencing sleep deprivation, most clients are alert and awake after birth of a neonate. Situational low self-esteem is not a priority. Clients who undergo a cesarean birth commonly feel a sense of failure because of not having a vaginal birth experience, but this is not the case for this client.
The nurse is caring for a primiparous client and her neonate immediately after birth. The neonate was born at 41 weeks’ gestation and weighs 4,082 g (9 lb). Assessing for signs and symptoms of which of the following conditions should be a priority in this neonate?
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Correct answer: D. Elevated bilirubin.
Postmature neonates commonly have difficulty maintaining adequate glucose reserves and usually develop hypoglycemia soon after birth. Other common problems include meconium aspiration syndrome, polycythemia, congenital anomalies, seizure activity, and cold stress. These complications result primarily from a combination of advanced gestational age, placental insufficiency, and continued exposure to amniotic fluid. Delayed meconium is not associated with postterm gestation. Hyperbilirubinemia occurs in term neonates as well as postterm neonates, but unless there is an Rh incompatibility it does not develop until after the first 24 hours of life.
A primigravid client at 39 weeks’ gestation is admitted to the hospital in active labor. On admission, the client’s cervix is 6 cm dilated. After 2 hours of active labor, the client’s cervix is still dilated at 6 cm with 100% effacement at +1 station. Contractions are 3 to 5 minutes apart, lasting 45 seconds, and of moderate intensity. The nurse determines that the client is most likely experiencing which of the following?
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Correct answer: A. Renal dysfunction.
If a client has been in active labor and there is no change in cervical dilation after 2 hours, the nurse should suspect cephalopelvic disproportion. This may be caused by an inadequate pelvis size of the mother or by a large-for-gestational-age fetus. The primary health care provider should be notified about the client’s lack of progress. If the fetus cannot descend, a cesarean birth is warranted. The client is not experiencing a prolonged latent phase (0 to 3 cm dilation), because her cervix is dilated to 6 cm. She has not reached the transitional phase, characterized by a cervical dilation of 8 to 10 cm. With a hypotonic labor pattern, contractions are painful but far apart and not very intense. This client’s contractions are of moderate intensity.
The primary health care provider who elects to perform a cesarean birth on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client’s husband says, "I’ll sign it for her. She’s too upset by what is happening to make this decision." The nurse should:
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Correct answer: C. Have the client and her husband both sign the consent form.
Preparation for cesarean birth is similar to preparation for any abdominal surgery. The client must give informed consent. Another person may not sign for the client unless the client is unable to sign the form. If this is the case, only certain designated people can do so legally. The husband does not need to sign the form unless his wife is unable to do so. In an emergency, surgery may be performed without a written consent if it is done to save the life of the mother or the child, or both.
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which of the following?
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Correct answer: C. Effects of analgesic medication.
Decreased variability may be seen in various conditions. However, it is most commonly caused by analgesic administration. Other factors that can cause decreased variability include anesthesia, deep fetal sleep, anencephaly, prematurity, hypoxia, tachycardia, brain damage, and arrhythmias. Maternal fatigue, fetal malposition, and small-for-gestational-age fetus are not commonly associated with decreased variability.
During a scheduled cesarean birth of a primigravid client with a fetus at 39 weeks’ gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which of the following?
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Correct answer: C. Respiratory distress syndrome.
Respiratory distress syndrome is more common in neonates born by cesarean section than in those born vaginally. During a vaginal birth, pressure is exerted on the fetal chest, which aids in the fetal inhalation and exhalation of air and lung expansion. This pressure is not exerted on the fetus with a cesarean birth. Congenital anomalies are not more common with cesarean birth. Pulmonary hypertension occurs more commonly in infants with meconium aspiration syndrome, congenital diaphragmatic hernia, respiratory distress syndrome, or neonatal sepsis, not with cesarean birth. Meconium aspiration syndrome occurs more commonly with vaginal birth, postterm neonate, and prolonged labor, not with cesarean birth.
A 28-year-old multigravid client at 28 weeks’ gestation diagnosed with acute pyelonephritis is receiving intravenous fluids and antibiotics. After teaching the client about the rationale for the aggressive therapy, the nurse determines that the client needs further instruction when she says that acute pyelonephritis can lead to which of the following?
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Correct answer: B. Brain damage.
Congenital anomalies are not related to maternal urinary tract infections. A multigravid client with acute pyelonephritis is susceptible to preterm labor, premature rupture of the membranes, maternal sepsis, intrauterine growth retardation, and fetal loss. The most common organism responsible for the urinary tract infection is Escherichia coli.
A primigravid client at 38 weeks’ gestation is admitted to the labor suite in active labor. The client’s physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which of the following?
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Correct answer: B. Conjunctivitis.
Conjunctivitis is a common complication of neonates who are born to mothers with untreated chlamydial infection. Neonatal pneumonia is another condition associated with chlamydial infection of the mother. Untreated chlamydial infection is not associated with heart disease or brain damage. Exposure to rubella may lead to neonatal heart defects, and brain damage may occur as a result of prolonged shoulder dystocia or difficulty delivering the fetal head during a vaginal breech birth. Occasionally, because of immature circulation, a neonate who has been lying on his or her side appears red on one side of the body. This "harlequin sign" is transient and is of no clinical significance. Presence of a harlequin sign is unrelated to untreated chlamydial infection.
A 16-year-old primigravid client admitted at 38 weeks’ gestation with severe preeclampsia is given intravenous magnesium sulfate and lactated Ringer’s solution. The nurse should obtain which of the following information?
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Correct answer: A. Respiratory rate every hour.
Because magnesium sulfate is a central nervous system depressant, the nurse should plan to assess the client’s respiratory rate every hour. If the respiratory rate is <12 breaths/min, the client may be experiencing magnesium sulfate overdose. Urinary output via an indwelling catheter should be assessed hourly and should be at least 30 mL/h. Deep tendon reflexes and blood pressure should also be assessed every hour. At some institutions continuous electronic blood pressure monitoring will be performed.
During admission, a multigravida in early active labor acts somewhat euphoric and tells the nurse that she smoked some crack cocaine before coming to the hospital. In addition to fetal heart rate assessment, the nurse should monitor the client for symptoms of which of the following?
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Correct answer: B. Abruptio placentae.
Dramatic vasoconstriction occurs as a result of sniffing crack cocaine. This can lead to increased respiratory and cardiac rates and hypertension. It can severely compromise placental circulation, resulting in abruptio placentae and preterm labor and birth. Infants of these women can experience intracranial hemorrhage and withdrawal symptoms of tremulousness, irritability, and rigidity. Placenta previa, ruptured uterus, and maternal hypotension are not associated with cocaine use. Placenta previa may be associated with grand multiparity. Ruptured uterus may be associated with a large-for-gestational-age fetus.
A primigravid client in early labor tells the nurse that she was exposed to rubella at about 14 weeks’ gestation. After birth, the nurse should assess the neonate for which of the following?
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Correct answer: D. Cardiac disorders.
Pregnant women who become infected with the rubella virus early in pregnancy risk having a neonate born with rubella syndrome. The symptoms include thrombocytopenia, cataracts, cardiac disorders, deafness, microcephaly, and motor and cognitive impairment. The most extensive neonatal effects occur when the mother is exposed during the first 2 to 6 weeks and up to 12 weeks’ gestation, when critical organs are forming. Bulging fontanels are associated with increased intracranial pressure and meningitis, which can occur as the result of a b-hemolytic streptococcal infection.
A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which of the following should the nurse expect the primary health care provider to prescribe?
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Correct answer: D. Fresh-frozen platelets.
To stop the process of DIC, the underlying insult that began the phenomenon must be halted. Treatment includes fresh-frozen platelets or blood administration. The primary health care provider also may prescribe heparin before the administration of blood products to restore the normal clotting mechanism. Immediate birth of the fetus is essential. Magnesium sulfate is given for pregnancy-induced hypertension or preterm labor. Heparin, not warfarin sodium (Coumadin), is used to treat DIC. Meperidine hydrochloride (Demerol) is used for pain relief.
A multigravid client diagnosed with chronic hypertension is now in preterm labor at 34 weeks’ gestation. The primary health care provider has prescribed magnesium sulfate at 3 g/h. Which assessment finding indicates that the intended therapeutic effect has occurred?
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Correct answer: A. Decrease in the frequency and number of contractions.
The intended effect for this client is to decrease the number and frequency of contractions. Even though this client has chronic hypertension, the first goal is to prevent childbirth in a 34 weeks’ gestation client. If the blood pressure moves into the therapeutic range, that is a benefit for the client but it is not the major goal. Magnesium sulfate may decrease the accelerations found in this fetus as it decreases the ability of the infant to respond, acting on the infant in the same way it does on the mother. Maternal respiratory rate may also decrease, and a lower respiratory rate to 12 respirations/minute indicates that this level of magnesium sulfate is becoming toxic to this client.
A primigravid client who was successfully treated for preterm labor at 30 weeks’ gestation had a history of mild hyperthyroidism before becoming pregnant. The nurse should instruct the client to do which of the following?
Show answer and rationale
Correct answer: C. Continue taking low-dose oral propylthiouracil as prescribed.
Although thioamides such as propylthiouracil and methimazole are considered teratogenic to the fetus and can lead to congenital hyperthyroidism (goiter) in the neonate, they still represent the treatment of choice. The client should be regulated on the lowest possible dose. Hyperthyroidism is associated with preterm labor and a low-birth-weight infant, so the client should contact the primary health care provider if the contractions begin again. The client should not be urged to breast-feed, because medications such as propylthiouracil and methimazole are secreted in breast milk. Tachycardia (not bradycardia) is associated with thyroid storm, a medical emergency, and should be reported to the primary health care provider.
While assessing a primigravid client admitted at 36 weeks’ gestation, the nurse observes multiple bruises on the client’s face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, "I want to leave him because I’m afraid he will hurt the baby." Which of the following actions is the nurse’s most appropriate response?
Show answer and rationale
Correct answer: A. Refer the client to a social worker for possible options.
In an abusive situation, the client’s safety is the priority. The nurse should refer the client to a social worker who can provide the client with options such as a safe shelter. Commonly clients who are battered feel powerless and fear that the batterer will kill them. As a result, they remain in the abusive situation. Telling the client to leave the boyfriend immediately is not helpful and reflects the values of the nurse. Although asking about fetal movement is important and is part of a routine assessment, a sonogram can be performed to confirm fetal well-being. The referral is more important at this time. Although it may be part of the unit’s policies and procedures to report any incidents such as this one to the unit supervisor, the client’s immediate need for safety must be addressed first.
A multigravid client in active labor at term suddenly sits up and says, "I can’t breathe! My chest hurts really bad!" The client’s skin begins to turn a dusky gray color. After calling for assistance, which of the following should the nurse do next?
Show answer and rationale
Correct answer: B. Administer oxygen by face mask.
The client’s symptoms are indicative of amniotic fluid embolism, which is a medical emergency. After calling for assistance, the first action should be to administer oxygen by face mask or cannula to ensure adequate oxygenation of mother and fetus. If the client needs cardiopulmonary resuscitation, this can be started once oxygen has been administered. If the client survives, disseminated intravascular coagulation will probably develop, and the client will need intravenous fibrinogen and heparin. Oxytocin, a vasoconstrictor, is not warranted for amniotic fluid embolism.
The nurse is working on a busy labor and birth unit with other nurses and a licensed practical nurse. Which of the following labor clients would the nurse assign to the licensed practical nurse?
Show answer and rationale
Correct answer: A. A G 2, P 1 client with a history of hyperemesis gravidarum.
Delegation of duties and clients to ancillary personnel is commonly the responsibility of the registered nurse. The client who is a G 2, P 1, with a history of hyperemesis gravidarum, is the client with the least potential for labor complications. Hyperemesis gravidarum typically occurs and is treated in the first or second trimester of pregnancy and should be resolved by this point in the pregnancy. A G 4, P 3 client with a history of gestational diabetes may have cephalopelvic disproportion due to a large-for-gestational-age fetus requiring a cesarean section. The G 3, P 1, Ab 1 client is preterm at 35 weeks’ gestation and may require an intensive care neonatal team. In a G 1, P 0 client, leaking green amniotic fluid indicates that there has been fetal distress.
A newly postpartum client is asking to go to the bathroom 45 minutes after childbirth. She had an epidural for labor and birth, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
Show answer and rationale
Correct answer: C. Assess client’s ability to stand and bear weight before going to the bathroom.
The nurse will need to assess the client’s ability to bear weight before taking her to the bathroom. If she cannot bear weight, she will be unable to ambulate. Asking the client to remain in bed until the assessments are complete sets the client up for increased postpartum bleeding, as the bladder will displace the uterus. Encouraging the client to sit at the bedside is an excellent strategy to prevent orthostatic hypotension, but will not give the nurse an idea if the client can ambulate. Having a staff member with the client is also correct for the first ambulation of this client, but the ability to bear weight and walk will need to be assessed first.
The charge nurse is preparing for the day shift on the labor and birth unit. Which of the following would be included in the responsibilities for this position?
Show answer and rationale
Correct answer: C. All of the above
In most settings, the charge nurse coordinates and directs the activities of the unit. Prior to the change of shift, the nurse will review and update the status of each of the laboring clients on the unit to include any difficulties or unusual situations that may be occurring with each of them, including following up with a primary nurse after a birth. A change-of-shift report with the oncoming charge nurse is among the last activities completed before ending the shift. Activities such as admitting a client in labor and completing the nursing responsibilities of the nurse who had to leave 30 minutes early can be delegated to staff members. In an emergency, the charge nurse could assume responsibility for client care.
The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?
Show answer and rationale
Correct answer: A. A client who is at 42 weeks’ gestation with bloody show, no contractions, ROM 1 hour ago leaking green fluid.
The client at 42 weeks’ is the greatest concern and the nurse should make rounds on this client first based on the length of the pregnancy and the green color of the amniotic fluid. Bloody show is a normal sign of impending labor as the cervix may be beginning to dilate. Not having contractions after rupture of membranes is not unusual within a 1-hour time frame. The green amniotic fluid indicates that fetal distress has recently occurred to the point that the fetus had a bowel movement in utero. Along with the 42-week gestation, this fetus is at greatest risk. The nurse can see the primipara in active labor at 5 cm dilation last; this client is in pain but nothing about her situation indicates anything but a normal labor process and as a primipara, her labor process will be slow. The client that is completely effaced, 8 cm dilated and at +2 station as a primipara usually moves through labor at a slower pace than a multiparous client. She is experiencing nausea that is an expected situation as a laboring client enters transition. The client with no prenatal care is a cause for concern as the nurse knows nothing about her background. Her blood pressure is elevated, an indicator of mild preeclampsia, but there is no other indications of worsening preeclampsia, such as headache, visual disturbances, or epigastric pain.
The triage nurse is giving a telephone report to the receiving nurse in the labor and birth unit. The client is a G4 P3 who is 8 cm dilated and is being transferred to the labor and birth unit. How should the labor and birth nurse manage the next ten minutes with the client?
Show answer and rationale
Correct answer: B. All of the above
Assuring the safety of this client is the top priority. The nurse should place the client on the fetal and contraction monitor. Since the client is 8 cm dilated and a multigravid client, asking other staff members to set up the birthing table would be in order. This client is not a candidate for medication as this may have an influence on the baby. This client is past the point of offering an epidural as she may have given birth by the time the medication is in effect, but comfort measures such as warm or cool cloths, back rubs, etc. may be helpful. The support system is an important aspect of the birthing process and is an easily settled situation. Preparing to give an early report to the oncoming nurse does not apply in this situation.
A client has experienced a postpartum hemorrhage. The primary health care provider verbally ordered carboprost tromethamine (Hemabate) 0.25 mg IM stat at the time of the hemorrhage and this was given by the nurse. The primary health care provider put a prescription into the electronic medical record for 0.25 mg carboprost tromethamine IV stat. When seeing the prescription, how should the nurse administering the carboprost tromethamine respond?
Show answer and rationale
Correct answer: B. Call the primary health care provider, discuss the prescription, and request revision if heard correctly.
In emergency situations, verbal prescriptions should be entered into the electronic medical record or chart and signed immediately after the emergency. The nurse taking this prescription and giving the medication needs to call the primary health care provider, explain the prescription and that the medication was administered per the verbal prescription, and request that the primary health care provider write the correct prescription. If the nurse misunderstood the prescription and gave the medication by the wrong route, an incident report will need to be initiated. The charge nurse would become involved if an error has occurred, an incident report is needed, or there is difficulty between the nurse and primary health care provider that cannot be remediated. Rectifying this prescription is the responsibility of the implementing nurse. Waiting until the primary health care provider comes back to the hospital unit may not occur quickly enough to safely care for the client.
The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which of the following?
Show answer and rationale
Correct answer: D. All of the above
The Code of Ethics describes those actions by the nurse that guide their practice. It is the responsibility of each nurse to be active in determining policy for health care for all citizens and assuring that the way nursing is practiced is of the highest caliber. Nursing needs to participate in the development of health care of the future, such as the EMR (electronic medical record), while caring for all members of society. In order to be productive in shaping policy, nurses need to be politically astute while growing personally and professionally to meet the needs of patients. The Code of Ethics does not address compensation for work.
The nurse from the nursery is bringing a newborn to a mother’s room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which of the following next to ensure the safest transition of the infant to the mother?
Show answer and rationale
Correct answer: D. Complete the hospital identification procedure with mother and infant.
The hospital identification procedures for mothers and infants need to be completed each time a newborn is returned to a family’s room. It does not matter how well the nurse knows the mother and infant; this validation is a standard of care in an obstetrical setting. Assessing the mother’s ability to ambulate, asking the mother if there is anything else she needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the process of transferring a baby to the mother, but identification verification is a safety measure that must occur first.
The nurse is caring for a G 3, T 3, P 0, Ab 0, L 3 woman who is 1 day postpartum following a vaginal birth. Which of the following indicates a need for further assessment?
Show answer and rationale
Correct answer: B. Temperature of 100.8°F (38.2°C).
Within the first 24 hours postpartum, maternal temperature may increase to 100.4°F (38.2°C), a normal postpartum finding attributed to dehydration. A temperature above 100.4°F (38.2°C) after the first 24 hours indicates a potential for infection. The hemoglobin is in the normal range. WBC count is normally elevated as a response to the inflammation, pain, and stress of the birthing process. A pulse rate of 60 bpm is normal at this period and results from an increased cardiac output (mobilization of excess extracellular fluid into the vascular bed, decreased pressure from the uterus on vessels, blood flow back to the heart from the uterus returning to the central circulation) and alteration in stroke volume.
The nurse is providing follow-up care with clients 1 week after the birth of their neonate. The nurse would anticipate what outcomes from this new mother?
Show answer and rationale
Correct answer: D. All of the above
Outcome evaluation for a family about 10 days after childbirth would include a mother who is tired but is able to care for herself and her baby. Having adequate support systems enables the mother to care better for herself and family members, as they can provide the backup for situations that may arise and a resource for new families. The normal progression for lochia is to change from red to pink to off-white while decreasing in amount. This is within the usual time periods for a postpartum mother. The baby should be feeding more frequently than every 6 to 8 hours. It is expected that a 10-day-old infant feeds every 3 to 4 hours if bottle-feeding and every 1� to 3 hours if breast-feeding. Follow-up questions the nurse would ask to further evaluate this situation include, How many wet diapers the infant has daily? How alert the infant is? Did the infant gain any weight at the first checkup? It is expected that the mother has positive comments about the infant, but the nurse will evaluate to determine if there is at least one positive comment.
A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is having pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?
Show answer and rationale
Correct answer: A. Administer pain medication per prescription.
Pain medication is the first strategy to initiate at this pain level. When trauma has occurred to any area, the usual intervention is ice for the first 24 hours and heat after the first 24 hours. Sitz baths are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays can also be utilized for the perineal area when pain is involved but would not lower the pain to a level that the client considers tolerable.
A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?
Show answer and rationale
Correct answer: B. The client will demonstrate self-care and infant care by the end of the shift.
Educating the client about caring for herself and her infant are the two highest priority goals. Following childbirth, all mothers, especially the primigravida, require instructions regarding self-care and infant care. Learning needs should be assessed in order to meet the specific needs of each client. Bonding is significant, but is only one aspect of the needs of this client and the bonding process would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the discharge occurs after the initial education has taken place for mother and infant and the nurse is aware of any need for referrals. Safety is an aspect of education taught continuously by the nurse and should include maternal as well as newborn safety.
In response to the nurse’s question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?
Show answer and rationale
Correct answer: C. Taking hold.
The client is in the taking hold phase with a demonstrated focus on the neonate and learning about and fulfilling infant care and needs. The taking in phase is the first period after birth where there is emphasis on reviewing and reliving the labor and birth process, concern with self, and needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks postpartum when the mother may be preparing to go back to work. During this time, she can have other individuals assume care of the infant and begin the separation process.
A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which of the following actions in the infant’s plan of care?
Show answer and rationale
Correct answer: B. Urine toxicology screening.
A urine toxicology screening will be collected to document that the infant has been exposed to illegal drug use. This documentation will be the basis for legal action for the protection of this infant. If the infant tests positive for cocaine, the legal system will be activated to provide and ensure protective custody for this child. Hospital security would not become involved unless the mother is obtaining or using drugs on hospital premises. The mother and infant have the same privileges as any hospitalized clients unless the safety of the infant is jeopardized; thus, limiting contact with visitors would not be appropriate. Local law enforcement agencies would be contacted only if the mother initiates use of drugs on hospital premises and such contact would be made through the hospital security system.
The nurse is evaluating the client who gave birth vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the prescriptions sheet would be the most appropriate for this client?
Show answer and rationale
Correct answer: D. Acetaminophen and hydrocodone 10 mg 1 tab PO every 4 to 6 hour PRN.
Acetaminophen and hydrocodone would be the drug of choice for this situation because the pain level is so high. Aspirin is not usually used because of the bleeding risk associated with its use. Although ibuprofen would typically be a good choice because it inhibits the prostaglandin synthesis associated with a multiparous client breast-feeding, the pain level is too high for this drug to have an acceptable effect. Docusate is used as a stool softener postpartum but does not provide pain relief.
At which of the following locations would the nurse expect to palpate the fundus of a primiparous client immediately after birth of a neonate?
Show answer and rationale
Correct answer: D. Halfway between the umbilicus and the symphysis pubis.
Immediately after delivery of the placenta, the nurse would expect to palpate the fundus halfway between the umbilicus and the symphysis pubis. Within 2 hours postpartum, the fundus should be palpated at the level of the umbilicus. The fundus remains at this level or may rise slightly above the umbilicus for approximately 12 hours. After the first 12 hours, the fundus should decrease one fingerbreadth (1 cm) per day in size. By the 9th or 10th day, the fundus usually is no longer palpable.
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following?
Show answer and rationale
Correct answer: B. Blindness secondary to gonorrhea.
The instillation of erythromycin into the neonate’s eyes provides prophylaxis for ophthalmia neonatorum, or neonatal blindness caused by gonorrhea in the mother. Erythromycin is also effective in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the neonate’s eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a mother with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts. Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial meningitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure to rubella. Erythromycin ointment is also not effective for preventing and treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age.
The physician prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following?
Show answer and rationale
Correct answer: B. Hemorrhage.
Vitamin K acts as a preventive measure against neonatal hemorrhagic disease. At birth, the neonate does not have the intestinal flora to produce vitamin K, which is necessary for coagulation. Hypoglycemia is prevented and treated by feeding the infant. Hyperbilirubinemia severity can be decreased by early feeding and passage of meconium to excrete the bilirubin. Hyperbilirubinemia is treated with phototherapy. Polycythemia may occur in neonates who are large for gestational age or postterm. Clamping of the umbilical cord before pulsations cease reduces the incidence of polycythemia. Generally, polycythemia is not treated unless it is extremely severe.
A grand-multiparous client has just given birth to a large-for-gestational-age infant. The nurse determines the client’s primary risk is for:
Show answer and rationale
Correct answer: A. Fluid volume deficit.
The primary risk is for fluid volume deficit related to blood loss. The client is at increased risk for uterine atony and therefore increased blood loss due to having given birth to five or more children and for having a large infant. The client may be at risk for pain, ineffective breast-feeding, and knowledge deficit, but there is not enough information to indicate that these are priority problems at this time.
The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal birth. The nurse should next:
Show answer and rationale
Correct answer: C. Apply an ice pack to the perineal area.
The client has a hematoma. During the first 24 hours postpartum, ice packs can be applied to the perineal area to reduce swelling and discomfort. Ice packs usually are not effective after the first 24 hours. Although vital signs, including temperature, are important assessments, taking the client’s temperature is unrelated to the hematoma and would provide no additional information about swelling. After 24 hours, the client may obtain more relief by taking a warm sitz bath. This moist heat is an effective way to increase circulation to the perineum and provide comfort. Usually, hematomas resolve without further treatment within 6 weeks. Additionally, the nurse should measure the hematoma to provide a baseline for subsequent measurements and should notify the physician of its presence. An antibiotic is not warranted at this point because the client is not exhibiting any signs or symptoms of infection.
Two hours after the vaginal birth of a viable male neonate under epidural anesthesia, a client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client’s bladder, finding it distended. The nurse interprets this finding based on the understanding that the client’s bladder distention is most likely caused by which of the following?
Show answer and rationale
Correct answer: C. Edema in the lower urinary tract area.
Urinary retention soon after childbirth is usually caused by edema and trauma of the lower urinary tract; this commonly results in difficulty with initiating voiding. Hyperemia of the bladder mucosa also commonly occurs. The combination of hyperemia and edema predisposes to decreased sensation to void, overdistention of the bladder, and incomplete bladder emptying. A prolonged first stage of labor can contribute to exhaustion and uterine atony, not urinary retention. If the client had a urinary tract infection, she would exhibit symptoms such as dysuria and a burning sensation. After birth, the uterus is contracting, which leads to less pressure on the bladder. Pressure of the uterus on the bladder occurs during labor.
A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate?
Show answer and rationale
Correct answer: B. "It will probably be 6 to 10 weeks before it starts again."
For clients who are bottle-feeding, the menstrual flow should return in 6 to 10 weeks, after a rise in the production of follicle-stimulating hormone by the pituitary gland. Nonlactating mothers rarely ovulate before 4 to 6 weeks postpartum. Therefore, 3 to 4 weeks is too early for the menstrual cycle to resume. For women who are breast-feeding, the menstrual flow may not return for 3 to 4 months (12 to 16 weeks) or, in some women, for the entire period of lactation, because ovulation is suppressed.
While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal birth under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following?
Show answer and rationale
Correct answer: B. Decreased blood volume in the vascular system.
The client’s dizziness is most likely caused by orthostatic hypotension secondary to the decreased volume of blood in the vascular system resulting from the physiologic changes occurring in the mother after birth. The client is experiencing dizziness because not enough blood volume is available to perfuse the brain. The nurse should first allow the client to "dangle" on the side of the bed for a few minutes before attempting to ambulate. By 6 hours postpartum, the effects of the anesthesia should be worn off completely. Typically, the effects of epidural anesthesia wear off by 1 to 2 hours postpartum, and the effects of local anesthesia usually disappear by 1 hour. The client scenario provides no information to indicate that the client experienced any postpartum hemorrhage. Normal blood loss during birth should not exceed 500 mL.
The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico who speaks only Spanish and gave birth to a viable term neonate 8 hours ago. When developing the postpartum dietary plan of care for the client, the nurse would encourage the client’s intake of which of the following?
Show answer and rationale
Correct answer: B. Meat products.
Because the diet of immigrants from Mexico and Central America commonly includes beans, corn products, tomatoes, chili peppers, potatoes, milk, cheeses, and eggs, the nurse needs to encourage an intake of meats, dark green leafy vegetables, and other high-protein products that are rich in iron. Doing so helps to compensate for the significant blood loss and subsequent iron loss that occurs during the postpartum period. Additionally, fresh fruits, meats, and green leafy vegetables may be scarce, possibly resulting in deficiencies of vitamin A, vitamin D, and iron. Tomatoes are high in vitamin C, potatoes are good sources of carbohydrates and vitamin C, and corn products are high in thiamine, but these are not rich sources of iron.
Three hours postpartum, a primiparous client’s fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which of the following conditions should the nurse assess further?
Show answer and rationale
Correct answer: B. Perineal lacerations.
A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained placental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspection. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case the fundus would be soft, possibly boggy, and displaced from midline.
At a postpartum checkup 11 days after childbirth, the nurse asks the client about the color of her lochia. Which of the following colors is expected?
Show answer and rationale
Correct answer: C. White.
On about the eleventh postpartum day, the lochia should be lochia alba, clear or white in color. Lochia rubra, which is dark red to red, may persist for the first 2 to 3 days postpartum. From day 3 to about day 10, lochia serosa, which is pink or brown, is normal.
After instructing a primiparous client about episiotomy care, which of the following client statements indicates successful teaching?
Show answer and rationale
Correct answer: C. "I wipe the area from front to back using a blotting motion."
The nurse should instruct the client to cleanse the perineal area with warm water and to wipe from front to back with a blotting motion. Warm water is soothing to the tender tissue, and wiping from front to back reduces the risk of contamination. Hot, sudsy water may increase the client’s discomfort and may even burn the client in a very tender area. After the first 24 hours, warm water sitz baths taken three or four times a day for 20 minutes can help increase circulation to the area. Ice packs are helpful for the first 24 hours.
A primiparous client, 20 hours after childbirth, asks the nurse about starting postpartum exercises. Which of the following would be most appropriate to include in the nurse’s instructions?
Show answer and rationale
Correct answer: B. Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles.
After an uncomplicated birth, postpartum exercises may begin on the first postpartum day with exercises to strengthen the abdominal muscles. These are done in the supine position with the knees flexed, inhaling deeply while allowing the abdomen to expand and then exhaling while contracting the abdominal muscles. Exercises such as sit-ups (sitting, then lying back, and returning to a sitting position) and push-ups or exercises involving reaching for the knees are ordinarily too strenuous for the first postpartum day. Sit-ups may be done later in the postpartum period, after approximately 3 to 6 weeks.
A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explaining to the client about the increased lochia on ambulation?
Show answer and rationale
Correct answer: D. The increased lochia occurs from lochia pooling in the vaginal vault.
Lochia can be expected to increase when the client first ambulates. Lochia tends to pool in the uterus and vagina when the client is recumbent and flows out when the client arises. If the client had reported that her lochia was bright red, the nurse would suspect bleeding. In this situation, the client would be put back in bed and the physician would be notified. Early postpartum hemorrhage occurs during the first 24 hours, but typically the fundus is soft or "boggy." The client’s fundus here is firm and midline. Late postpartal hemorrhage, occurring after the first 24 hours, is usually caused by retained placental fragments or abnormal involution of the placental site.
Four hours after giving spontaneous vaginal birth under epidural anesthesia to a viable neonate, the client states she needs to urinate. The nurse should next:
Show answer and rationale
Correct answer: A. Measure the first two voidings and record the amount.
After birth, the nurse should plan to measure the client’s first two voidings and record the amount to make sure that the client is emptying the bladder. Frequent voidings of less than 150 mL suggest that the client is experiencing urinary retention. In addition, if urinary retention is occurring, the bladder may be palpable and the fundus may be displaced from midline. The client does not need to be catheterized unless there is evidence of urinary retention. Palpation of the bladder before voiding is unnecessary. However, if the client has difficulty voiding or exhibits signs of urinary retention, then bladder palpation is indicated. The fundus can be displaced by a full bladder and should be assessed after the client voids.
A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining near the client to assess for which of the following?
Show answer and rationale
Correct answer: B. Fainting.
Clients sometimes feel faint or dizzy when taking a shower for the first time after birth because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes her first shower after birth. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect her privacy, stay with the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower. Diuresis is a normal physiologic response during the postpartum period and not associated with showering. Hygiene needs also precede the shower.
A primiparous client who gave birth 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate?
Show answer and rationale
Correct answer: A. "Squeeze your buttock muscles together before sitting down."
The nurse should instruct the client to squeeze or contract the muscles of the buttocks together before sitting down in the chair; this contracts the pelvic floor muscles, which reduces the tension on the tender perineal area. Then the client should put her full weight slowly down on the chair. Pain medication may only be prescribed for every 3 to 4 hours, so the client may not be able to receive pain medication every time she desires to sit in the chair. The episiotomy pain usually fades by the fifth or sixth postpartum day. Maintaining a relaxed posture before sitting does not contract the pelvic floor muscles. Most physicians prescribe an analgesic cream or spray when a client has an episiotomy, but they provide only temporary relief.
A primiparous client has just given birth to a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse interprets the father’s actions as indicative of which of the following?
Show answer and rationale
Correct answer: D. Singing to his son from the Koran in praise of Allah.
The father is praying to Allah because of the Muslim belief that the first sounds a child hears should be from the Koran in praise of and supplication to Allah. Although male children are revered in this culture, this practice is performed by Muslims whether the child is male or female. The father’s actions are unrelated to his wife and son’s being healthy. The nurse should allow the practice because doing so demonstrates cultural sensitivity and builds a trusting relationship with the family. The Muslim faith does not have a baptism rite whereby the child becomes a member of the faith.
An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without "spoiling" him. Which of the following responses would be most appropriate?
Show answer and rationale
Correct answer: B. "Hold him as much as you want to hold him."
According to Erikson, infants are in the trust versus mistrust stage. Holding, talking to, singing to, and patting neonates helps them develop trust in caregivers. Tactile stimulation is important and should be encouraged. Holding neonates often is unlikely to spoil them because they are totally dependent on other human beings to meet their needs. Being held makes infants feel loved and cared for and should be encouraged. The mother can hold the neonate as often as she wants, not just when the baby is crying or fussy. Overstimulation typically does not result from holding an infant.
On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for:
Show answer and rationale
Correct answer: B. Perineal hematoma.
If the client continues to have perineal pain after an analgesic medication has been given, the nurse should inspect the client’s perineum for a hematoma, because this is the usual cause of such discomfort. Ibuprofen is a nonsteroidal anti-inflammatory medication used to relieve mild pain. Pain from a perineal hematoma can be moderate to severe, possibly requiring a stronger analgesic, such as acetaminophen with codeine (Tylenol with Codeine). Ice applied to the perineum during the first 24 hours postpartum may decrease the severity of hematoma formation. Application of warm heat, such as a sitz bath three times daily for 20 minutes, also can help to relieve the discomfort when implemented after the first 24 hours. Typically hematomas resolve themselves within 6 weeks. A puerperal infection would be indicated if the client’s temperature were 100.4�F (41�C) or higher. Also, lochia most likely would be foul smelling. A continuous trickle of lochia rubra would suggest a possible vaginal laceration. No evidence is presented to suggest a history of drug abuse.
The nurse assigns an unlicensed assistive personnel to care for a client who is 1 day postpartum. Which of the following would be appropriate to delegate to this person?
Show answer and rationale
Correct answer: C. All of the above
Delegating care to unlicensed assistive personnel requires that the nurse knows which tasks are within their capability. Changing the perineal pad and reporting drainage, reinforcing hygiene with perineal care, and assisting with ambulation are within the individual’s capacity. Unlicensed assistive personnel should never be asked to complete any assessments, such as checking fundal location or performing skilled procedures on a client. In addition, it would be beyond the scope of the job of unlicensed assistive personnel to assist the mother with latching on and discussing postpartum depression with the client. State Boards of nursing list the procedures and tasks that unlicensed assistive personnel can complete when directed.
While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity? We were in labor together." Which of the following responses by the nurse would be most appropriate?
Show answer and rationale
Correct answer: B. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."
Legal regulations and ethical decision making require that the nurse maintain confidentiality at all times. The nurse’s best response is to explain to the client that nurses are not allowed to discuss other clients on the unit. Ignoring the client’s question is inappropriate because doing so would interfere with the development of a trusting nurse-client relationship. Confidentiality must be maintained at all times. Telling the client that the nurse isn’t sure may imply that the nurse will find out and then tell the client about the other woman. Asking the other woman’s permission to discuss her with another client is inappropriate because confidentiality must be maintained at all times.
A newly postpartum primiparous client asks the nurse, "Can my baby see?" Which of the following statements about neonatal vision should the nurse include in the explanation?
Show answer and rationale
Correct answer: B. They can see objects up to 12 inches (30.5 cm) away.
The neonate has immature oculomotor coordination, an inability to accommodate for distance, and poorly developed eyes, visual nerves, and brain. However, the normal neonate can see objects clearly within a range of 9 to 12 inches (22.9 to 30.5 cm), whether or not they are moving. Visual acuity at birth is 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Newborns can distinguish colors as well as light from dark.
While assessing the fundus of a multiparous client 36 hours after birth of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client:
Show answer and rationale
Correct answer: D. To perform exercises involving head and shoulder raising in a lying position.
The client is experiencing diastasis recti, a separation of the longitudinal muscles (recti) of the abdomen that is usually palpable on the third postpartum day. An exercise involving raising the head and shoulders about 8 inches (20.3 cm) with the client lying on her back with knees bent and hands crossed over the abdomen is preferred. This exercise helps to pull the abdominal muscles together and the client gradually works up to performing this exercise 50 times per day. However, until the diastasis has closed, the client should avoid exercises that rotate the trunk, twist the hips, or bend the trunk to one side, because further separation may occur. The condition does not need a surgical repair, and limited activity and bed rest are not necessary. Correct posture and adequate diet assist the body to return to its prepregnancy state more quickly but do not resolve the separation of abdominal muscles.
A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first?
Show answer and rationale
Correct answer: B. Catheterize the client.
A uterine fundus located off to one side and above the level of the umbilicus is commonly the result of a full bladder. Although the client had voided, the client may be experiencing urinary retention with overflow. If anesthesia has been used for birth, the inability to void may be related to the lingering effects of anesthesia; however, that is not the case here. Physicians commonly write a one-time order for catheterization, after which, typically, enough edema has subsided to make it easier and less painful for the client to void and completely empty her bladder. Administering ibuprofen would have no effect on the uterine fundus. Waiting to reassess in 1 hour could be detrimental since the client’s distended bladder is interfering with uterine involution, predisposing her to possible hemorrhage. Administering a bolus of fluid would be inappropriate because it would only add to the client’s full bladder.
While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which of the following responses would be most appropriate?
Show answer and rationale
Correct answer: A. "They usually fade to a silvery-white color over a period of time."
Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly over the abdomen. After birth, the tissues atrophy, leaving silver scars. These skin pigmentations will not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes pregnant again. Special creams are not warranted because they are not helpful and may be expensive. Weight loss does not make the marks disappear. Striae gravidarum tend to run in families.
A primiparous client who gave vaginal birth to a viable term neonate 48 hours ago has a midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge, which of the following assessments would be most important?
Show answer and rationale
Correct answer: C. Constipation
The client with a third-degree laceration should be assessed for constipation, because a third-degree laceration extends into a portion of the anal sphincter. Constipation, not diarrhea, is more likely because this condition is extremely painful, possibly causing the client to be reluctant to have a bowel movement. The laceration has been sutured and should not be bleeding at 48 hours postpartum. Rectal fistulas may develop at a later time, but not at 48 hours postpartum.
In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal birth with a midline episiotomy. The nurse should instruct the client that she can resume sexual intercourse:
Show answer and rationale
Correct answer: C. When lochia flow and episiotomy pain have stopped.
For most clients, sexual intercourse can be resumed when the lochia has stopped flowing and episiotomy pain has ceased, usually about 3 weeks postpartum. Sexual intercourse may be painful until the episiotomy has healed. The client also needs instructions about the possibility that pregnancy may occur before the return of the client’s menstrual flow. The postpartum check by the health care provider typically occurs 4 to 6 weeks after birth and most women have already had intercourse by this time. Typically, new mothers are exhausted and may not feel amorous or desirable for quite a while. In addition, the mother’s physiologic responses may be diminished because of low hormonal levels, adjustments to the maternal role, and fatigue due to lack of rest and sleep.
While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother’s temperature is 99.8�F (37.2�C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:
Show answer and rationale
Correct answer: C. Continue to monitor the client’s vital signs.
The nurse needs to continue to monitor the client’s vital signs. During the first 24 hours postpartum it is normal for the mother to have a slight temperature elevation because of dehydration. A temperature of 100.4�F (38�C) that persists after the first 24 hours may indicate an infection. Bradycardia during the first week postpartum is normal because of decreased blood volume, diuresis, and diaphoresis. The client’s respiratory rate is within normal limits. Large clots are indicative of hemorrhage. However, the client’s vital signs are within normal limits and her fundus is firm and midline. Therefore, large clots and possible hemorrhage can be ruled out. The physician does not need to be notified at this time. An ice pack is not necessary because the client’s temperature is within normal limits.
While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client’s rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which of the following client statements indicates the need for additional teaching?
Show answer and rationale
Correct answer: D. "I should lie on my back as much as possible to relieve the pain."
The client needs more teaching when she states, "I should lie on my back as much as possible to relieve the pain." Instead, the client should lie in the Sims position as much as possible to aid venous return to the rectal area and to reduce discomfort. Gentle manual replacement of the hemorrhoid is an appropriate measure to help relieve the discomfort and prevent enlargement. Analgesic sprays and witch hazel pads are helpful in reducing the discomfort of hemorrhoids. Drinking lots of water and eating roughage aid in bowel elimination, minimizing the risk of straining and subsequent hemorrhoidal development or enlargement.
A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client’s mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds based on the understanding about which of the following?
Show answer and rationale
Correct answer: D. The mother can bring the daughter any foods that she desires.
On most postpartum units, clients on regular diets are allowed to eat whatever kinds of food they desire. Generally, foods from home are not discouraged. The nurse does not need to obtain the physician’s permission. Although it is preferred, the foods do not necessarily have to be high in iron. In some cultures, there is a belief in the "hot-cold" theory of disease; certain foods (hot) are preferred during the postpartum period, and other foods (cold) are avoided. Therefore, the nurse should allow the mother to bring her daughter "special foods from home." Doing so demonstrates cultural sensitivity and aids in developing a trusting relationship.
A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following?
Show answer and rationale
Correct answer: B. Orange juice.
Iron is best absorbed in an acid environment or with vitamin C. For maximum iron absorption, the client should take the medication with orange juice or a vitamin C supplement. Herbal tea has no effect on iron absorption. Milk decreases iron absorption. Grape juice is not acidic and therefore would have no effect on iron absorption.
The nurse is caring for a multiparous client after vaginal birth of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to:
Show answer and rationale
Correct answer: B. Relate to each twin individually to enhance the attachment process.
It is believed that the process of attachment is structured so that the parents become attached to only one infant at a time. Therefore, the nurse should encourage the parents to relate to each twin individually, rather than as a unit, to enhance the attachment process. Mothers of twins are usually able to breast-feed successfully because the milk supply increases on demand. However, possible fatigue and exhaustion require that the mother rest whenever possible. It would be highly unlikely and unrealistic that each parent would be able to spend equal amounts of time with both twins. Other responsibilities, such as employment, may prevent this. The parents should try to engage assistance from family and friends, because caring for twins or other multiple births (eg, triplets) can be exhausting for the family.
Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next?
Show answer and rationale
Correct answer: C. Encourage the client to ambulate to the bathroom and void.
At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus, and deviated to the right rather than in the midline, the client’s bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void, because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding and if voiding does not return it to midline, it should be reported to the physician. Oxytocin is used to treat uterine atony. This client’s fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots.
A nurse is discussing discharge instructions with a client. Which of the following statements indicate that the client understands the resources and information available if needed after discharge?
Show answer and rationale
Correct answer: A. All of the above
The nurse is responsible for providing discharge instructions that include signs and symptoms that need to be reported to the physician as well as resources and follow-up for home care if needed. Phone numbers and health practices to promote healing, such as the use of prenatal vitamins, are also essential pieces of information. The use of birth control pills needs to be discussed with the physician. A progesterone-only pill is used if the client is breast-feeding. Oral contraceptives should be initiated according to the physician’s advice. Although the client’s mother may be helpful, the client’s statement that she will be fine because her mother is coming indicates that she is unaware or ignoring information about valuable information and resources.
The nurse is reviewing discharge instructions with a postpartum breast-feeding client who is going home. She has chosen medroxyprogesterone (Depo-Provera) as birth control. Which statement by the client identifies that she needs further instruction concerning birth control?
Show answer and rationale
Correct answer: B. "You will give me my first Depo-Provera shot before I leave today."
Depo-Provera is a progestin contraceptive that can reduce the initial production of breast milk. It is given to a breast-feeding woman when she returns for the 6-week postpartum checkup. By this time, the milk supply is well established and will remain at that level. Depo-Provera is effective as a contraceptive for 90 days. Clients who are bottle-feeding may be given Depo-Provera prior to discharge from the hospital
A postpartum primiparous client is having difficulty breast-feeding her infant. The infant latches on to the breast, but the mother’s nipples are extremely sore during and after each feeding. The client needs further instruction about breast-feeding when she states:
Show answer and rationale
Correct answer: C. "As long as some of my nipple is in the baby’s mouth, the baby will receive enough milk."
As much of the mother’s nipple and areola need to be in the infant’s mouth in order to establish a latch that does not cause nipple cracks or fissures. Having the nipple and the areola deep in the infant’s mouth decreases the stress on the end of the nipple, therefore decreasing pain, cracking, and fissures. Breast milk has been found to heal nipples when placed on the nipple at the completion of a feeding. The length of time the baby feeds on each nipple is not a factor as long as the nipple is correctly placed in the infant’s mouth.
The nurse is caring for a primipara who gave birth yesterday and has chosen to breast-feed her neonate. Which assessment finding is considered unusual for the client at this point postpartum?
Show answer and rationale
Correct answer: D. Milk production.
New mothers usually begin to produce milk at about the third day postpartum and colostrum is produced until that time. For clients who have breast-fed another infant during pregnancy, having milk shortly after birth is not unusual. Diaphoresis and diuresis are considered normal during this time as the body excretes the additional fluids that are no longer needed after the pregnancy. Constipation may continue for several days as a result of progesterone remaining in the system, the consummation of iron, and trauma to the perineum.
The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains?
Show answer and rationale
Correct answer: B. G 3, P 3 client who is breast-feeding her infant.
The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulates uterine contractions. There are no data to suggest any of these clients has had an overdistended uterus or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest parity of the clients listed, which-in addition to breast-feeding-places her most at risk for afterbirth pains. The G 2, P 2 postcesarean client may have cramping but it should be less than the G 3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because she has given birth to several children, but her choice to bottle-feed reduces her risk of pain.
A breast-feeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client has a warm, red, painful breast; a temperature of 100�F (37.7�C); and flulike symptoms. What should the nurse do?
Show answer and rationale
Correct answer: C. Refer the woman to her primary health care provider.
The client is exhibiting signs and symptoms of a breast infection (mastitis). The nurse should instruct her to contact her health care provider, who will likely prescribe a prescription for antibiotics. She should continue to breast-feed the infant from both breasts. Frequent breast-feeding is encouraged rather than discontinuing the process for anyone having a breast infection. Applying warm compresses may relieve pain. However, the underlying infection indicated by the elevated temperature indicates that additional treatment with antibiotics will be needed.
A diabetic postpartum client plans to breast-feed. The nurse determines that the client’s understanding of breast-feeding instructions is sufficient when she states:
Show answer and rationale
Correct answer: D. "Breast-feeding will assist in lowering maternal blood glucose."
Breast-feeding consumes maternal calories and requires energy that increases the maternal basal metabolic rate and assists in lowering the maternal blood glucose level. Insulin is not transferred to the infant through breast milk. Breast-feeding is recommended for diabetic mothers because it does lower blood glucose levels. The number of antibodies in breast milk is not altered by maternal diabetes
A 1-day-old breast-fed infant has a bilirubin level that is at an intermediate risk for jaundice. Which statement by the infant’s mother indicates an understanding of the teaching regarding jaundice?
Show answer and rationale
Correct answer: D. I should breast-feed my baby as often as possible.
Jaundice in a breast-feeding infant is common and is not pathological. Mothers should be taught to breast-feed as often as possible, at least every 2 to 3 hours and until the infant is satiated. Breast-fed babies rarely need to be supplemented with formula. Mothers should be encouraged to continue breast-feeding their infants due to the numerous benefits it provides. Infants should never be placed in direct sunlight.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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