MCN – POSTPARTUM statement by the nurse would further

assist the family in their initial period of

grief?
1. A rubella titer result of a 1-day postpartum 1. "What can I do for you?"
client is less than 1:8, and a rubella virus 2. "Now you have an angel in heaven."
vaccine is prescribed to be administered 3. "Don't worry, there is nothing you could
before discharge. The nurse provides have done to prevent this from
which information to the client about the happening."
vaccine? Select all that apply. 4. "We will see to it that you have an early
1. Breast-feeding needs to be stopped for discharge so that you don't have to be
3 months. reminded of this experience."
2. Pregnancy needs to be avoided for 1 to
3 months. 1. "What can I do for you?"
3. The vaccine is administered by the
subcutaneous route. 4. The nurse in a maternity unit is providing
4. Exposure to immunosuppressed emotional support to a client and her
individuals needs to be avoided. husband who are preparing to be
5. A hypersensitivity reaction can occur if discharged from the hospital after the birth
the client has an allergy to eggs. of a dead fetus. Which statement made by
6. The area of the injection needs to be the client indicates a component of the
covered with a sterile gauze for 1 week. normal grieving process?
o 2. Pregnancy needs to be avoided for 1. "We want to attend a support group."
1 to 3 months. 2. "We never want to try to have a baby
o 3. The vaccine is administered by the again."
subcutaneous route. 3. "We are going to try to adopt a child
o 4. Exposure to immunosuppressed immediately."
individuals needs to be avoided.
4. "We are okay, and we are going to try
o 5. A hypersensitivity reaction can
occur if the client has an allergy to to have another baby immediately."
eggs.
2. The nurse is providing instructions to a 1. "We want to attend a support group."
pregnant client with human
immunodeficiency virus (HIV) infection 5. The nurse evaluates the ability of a
regarding care to the newborn after hepatitis B–positive mother to provide
delivery. The client asks the nurse about safe bottle-feeding to her newborn during
the feeding options that are available. postpartum hospitalization. Which
Which response should the nurse make to maternal action best exemplifies the
the client? mother's knowledge of potential disease
1. "You will need to bottle-feed your transmission to the newborn?
newborn." 1. The mother requests that the window
2. "You will need to feed your newborn by be closed before feeding.
nasogastric tube feeding." 2. The mother holds the newborn properly
3. "You will be able to breast-feed for 6 during feeding and burping.
months and then will need to switch to 3. The mother tests the temperature of the
bottle-feeding." formula before initiating feeding.
4. "You will be able to breast-feed for 9 4. The mother washes and dries her
months and then will need to switch to hands before and after self-care of the
bottle-feeding." perineum and asks for a pair of gloves
before feeding.
1. "You will need to bottle-feed your newborn."
4. The mother washes and dries her hands
3. A stillborn baby was delivered in the before and after self-care of the perineum and
asks for a pair of gloves before feeding.
birthing suite a few hours ago. After the
delivery, the family remained together,
holding and touching the baby. Which
6. The nurse has provided discharge 1. Document the findings.
instructions to a client who delivered a 2. Retake the temperature in 15 minutes.
healthy newborn by cesarean delivery. 3. Notify the health care provider (HCP).
Which statement made by the client 4. Increase hydration by encouraging oral
indicates a need for further instruction? fluids.
1. "I will begin abdominal exercises
immediately." 4. Increase hydration by encouraging oral
2. "I will notify the health care provider if I fluids.
develop a fever."
3. "I will turn on my side and push up with 10. The nurse is assessing a client who is 6
my arms to get out of bed." hours postpartum after delivering a full-
4. "I will lift nothing heavier than my term healthy newborn. The client
newborn baby for at least 2 weeks." complains to the nurse of feelings of
faintness and dizziness. Which nursing
1. "I will begin abdominal exercises action would be most appropriate?
immediately." 1. Raise the head of the client's bed.
2. Obtain hemoglobin and hematocrit
7. After a precipitous delivery, the nurse levels.
notes that the new mother is passive and 3. Instruct the client to request help when
only touches her newborn infant briefly getting out of bed.
with her fingertips. What should the nurse 4. Inform the nursery room nurse to avoid
do to help the woman process the bringing the newborn to the client until the
delivery? mother's symptoms have subsided.
1. Encourage the mother to breast-feed
soon after birth. 3. Instruct the client to request help when
2. Support the mother in her reaction to getting out of bed.
the newborn infant.
3. Tell the mother that it is important to 11. The postpartum nurse is providing
hold the newborn infant. instructions to a client after delivery of a
4. Document a complete account of the healthy newborn. Which time frame
mother's reaction on the birth record. should the nurse relay to the client
regarding the return of bowel function?
2. Support the mother in her reaction to the 1. 3 days postpartum
newborn infant. 2. 7 days postpartum
3. On the day of delivery
8. The nurse in the postpartum unit is caring 4. Within 2 weeks postpartum
for a client who has just delivered a
newborn infant following a pregnancy with 1. 3 days postpartum
a placenta previa. The nurse reviews the
plan of care and prepares to monitor the 12. The nurse is planning care for a
client for which risk associated with postpartum client who had a vaginal
placenta previa? delivery 2 hours ago. The client had a
1. Infection midline episiotomy and has several
2. Hemorrhage hemorrhoids. What is the priority nursing
3. Chronic hypertension consideration for this client?
4. Disseminated intravascular coagulation 1. Client pain level
2. Inadequate urinary output
2. Hemorrhage 3. Client perception of body changes
4. Potential for imbalanced body fluid
9. The postpartum nurse is taking the vital volume
signs of a client who delivered a healthy
newborn 4 hours ago. The nurse notes 1. Client pain level
that the client's temperature is 100.2° F.
What is the priority nursing action?
13. The nurse is providing postpartum 2. Massage the fundus until it is firm.
instructions to a client who will be breast-
feeding her newborn. The nurse 16. The nurse is caring for four 1-day
determines that the client has understood postpartum clients. Which client would
the instructions if she makes which require further nursing action?
statements? Select all that apply. 1. The client with mild afterpains
1. "I should wear a bra that provides 2. The client with a pulse rate of 60
support." beats/minute
2. "Drinking alcohol can affect my milk 3. The client with colostrum discharge
supply." from both breasts
3. "The use of caffeine can decrease my 4. The client with lochia that is red and
milk supply." has a foul-smelling odor
4. "I will start my estrogen birth control
pills again as soon as I get home." 4. The client with lochia that is red and has a
5. "I know if my breasts get engorged I will foul-smelling odor
limit my breast-feeding and supplement
the baby." 17. When performing a postpartum
6. "I plan on having bottled water available assessment on a client, a nurse notes the
in the refrigerator so I can get additional presence of clots in the lochia. The nurse
fluids easily." examines the clots and notes that they are
o 1. "I should wear a bra that provides larger than 1 cm. Which nursing action
support." is most appropriate?
o 2. "Drinking alcohol can affect my milk 1. Document the findings.
supply." 2. Reassess the client in 2 hours.
o 3. "The use of caffeine can decrease 3. Notify the health care provider.
my milk supply."
4. Encourage increased oral intake of
o 6. "I plan on having bottled water
available in the refrigerator so I can
fluids.
get additional fluids easily."
14. The nurse is teaching a postpartum client 3. Notify the health care provider.
about breast-feeding. Which instruction
should the nurse include? 18. The nurse is monitoring the amount of
1. The diet should include additional lochia drainage in a client who is 2 hours
fluids. postpartum and notes that the client has
2. Prenatal vitamins should be saturated a perineal pad in 1 hour. How
discontinued. should the nurse document this finding?
3. Soap should be used to cleanse the 1. Scant
breasts. 2. Light
4. Birth control measures are unnecessary 3. Heavy
while breast-feeding. 4. Excessive

1. The diet should include additional fluids. 3. Heavy

15. A nurse is preparing to assess the uterine 19. The nurse is monitoring a client in the
fundus of a client in the immediate immediate postpartum period for signs of
postpartum period. After locating the hemorrhage. Which sign, if noted, would
fundus, the nurse notes that the uterus be an early sign of excessive blood loss?
feels soft and boggy. Which nursing 1. A temperature of 100.4° F
intervention would be most appropriate? 2. An increase in the pulse rate from 88 to
1. Elevate the client's legs. 102 beats/minute
2. Massage the fundus until it is firm. 3. A blood pressure change from 130/88
3. Ask the client to turn on her left side. to 124/80 mm Hg
4. Push on the uterus to assist in 4. An increase in the respiratory rate from
expressing clots. 18 to 22 breaths/minute
 2. An increase in the pulse rate from 88 to 102 23. A client in a postpartum unit complains of
beats/minute sudden sharp chest pain and dyspnea.
The nurse notes that the client is
20. The nurse is preparing a list of self-care tachycardic and the respiratory rate is
instructions for a postpartum client who elevated. The nurse suspects a
was diagnosed with mastitis. Which pulmonary embolism. Which should be
instructions should be included on the the initial nursing action?
list? Select all that apply. 1. Initiate an intravenous line.
1. Wear a supportive bra. 2. Assess the client's blood pressure.
2. Rest during the acute phase. 3. Prepare to administer morphine sulfate.
3. Maintain a fluid intake of at least 3000 4. Administer oxygen, 8 to 10 L/minute, by
mL. face mask.
4. Continue to breast-feed if the breasts
are not too sore. 4. Administer oxygen, 8 to 10 L/minute, by
5. Take the prescribed antibiotics until the face mask.
soreness subsides.
6. Avoid decompression of the breasts by 24. The nurse is assessing a client in the
breast-feeding or breast pump. fourth stage of labor and notes that the
o 1. Wear a supportive bra. fundus is firm, but that bleeding is
o 2. Rest during the acute phase. excessive. Which should be
o 3. Maintain a fluid intake of at least the initial nursing action?
3000 mL. 1. Record the findings.
o 4. Continue to breast-feed if the
breasts are not too sore.
2. Massage the fundus.
21. The nurse is providing instructions about 3. Notify the health care provider (HCP).
measures to prevent postpartum mastitis 4. Place the client in Trendelenburg's
to a client who is breast-feeding her position.
newborn. Which client statement would
3. Notify the health care provider (HCP).
indicate a need for further instruction?
1. "I should breast-feed every 2 to 3
hours." 25. The nurse is preparing to care for four
2. "I should change the breast pads assigned clients. Which client is at highest
frequently." risk for hemorrhage?
3. "I should wash my hands well before 1. A primiparous client who delivered 4
breast-feeding." hours ago
4. "I should wash my nipples daily with 2. A multiparous client who delivered 6
soap and water." hours ago
3. A primiparous client who delivered 6
4. "I should wash my nipples daily with soap hours ago and had epidural anesthesia
and water." 4. A multiparous client who delivered a
large baby after oxytocin (Pitocin)
22. The postpartum nurse is assessing a induction
client who delivered a healthy infant by
cesarean section for signs and symptoms 4. A multiparous client who delivered a large
baby after oxytocin (Pitocin) induction
of superficial venous thrombosis. Which
sign would the nurse note if superficial
venous thrombosis were present? 26. A postpartum client is diagnosed with
1. Paleness of the calf area cystitis. The nurse should plan for
2. Coolness of the calf area which priority nursing action in the care
3. Enlarged, hardened veins of the client?
4. Palpable dorsalis pedis pulses 1. Providing sitz baths
2. Encouraging fluid intake
3. Enlarged, hardened veins 3. Placing ice on the perineum
4. Monitoring hemoglobin and hematocrit
levels
 2. Encouraging fluid intake taken until it is finished."
3. "My fluid intake should be increased to
27. The nurse is monitoring a postpartum at least 3000 mL daily."
client who received epidural anesthesia 4. "Foods and fluids that will increase
for delivery for the presence of a vulvar urine alkalinity should be consumed."
hematoma. Which assessment finding
would best indicate the presence of a 4. "Foods and fluids that will increase urine
hematoma? alkalinity should be consumed."
1. Changes in vital signs
2. Signs of heavy bruising 31. The nurse is assessing a client for signs
3. Complaints of intense pain of postpartum depression. Which
4. Complaints of a tearing sensation observation, if noted in the new mother,
would indicate the need for further
1. Changes in vital signs assessment related to this form of
depression?
28. The nurse is developing a plan of care for 1. The mother is caring for the infant in a
a postpartum client with a small vulvar loving manner.
hematoma. The nurse should include 2. The mother demonstrates an interest in
which specific action during the first 12 the surroundings.
hours after delivery? 3. The mother constantly complains of
1. Assess vital signs every 4 hours. tiredness and fatigue.
2. Measure fundal height every 4 hours. 4. The mother looks forward to visits from
3. Prepare an ice pack for application to the father of the newborn.
the area.
4. Inform the health care provider of 3. The mother constantly complains of
assessment findings. tiredness and fatigue.

3. Prepare an ice pack for application to the 32. A postpartum client is attempting to
area. breast-feed for the first time. The nurse
notes that the client has inverted nipples.
29. On assessment of a postpartum client, the What nursing action should the nurse take
nurse notes that the uterus feels soft and to assist the client in breast-feeding the
boggy. The nurse should take newborn infant?
which initial action? 1. Massage the breasts, applying gentle
1. Elevate the client's legs. pressure on the areolas with the thumb
2. Document the findings. and forefinger.
3. Massage the fundus until it is firm. 2. Have the mother grasp her areola
4. Push on the uterus to assist in between the thumb and forefinger and tug
expressing clots. firmly to get the nipple to protrude.
3. Encourage taking a cool shower,
3. Massage the fundus until it is firm. allowing the water to run over the breasts,
because this will encourage the nipples to
30. On the second postpartum day, a client protrude.
complains of burning on urination, 4. Provide breast shells and assist the
urgency, and frequency of urination. A mother with using a breast pump before
urinalysis indicates the presence of a each feeding to make the nipples easier
urinary tract infection. The nurse instructs for the newborn infant to grasp.
the client regarding measures to take for
the treatment of the infection. Which client 4. Provide breast shells and assist the mother
statement indicates to the nurse the need with using a breast pump before each feeding
for further instruction? to make the nipples easier for the newborn
1. "I need to urinate frequently throughout infant to grasp.
the day."
2. "The prescribed medication must be
33. A new mother is seen in a health care 36. The nurse is monitoring a postpartum
clinic 2 weeks after giving birth to a client in the fourth stage of labor. Which
healthy newborn infant. The mother is finding, if noted by the nurse, would
complaining that she feels as though she indicate a complication related to a
has the flu and complains of fatigue and laceration of the birth canal?
aching muscles. On further assessment 1. Presence of dark red lochia
the nurse notes a localized area of 2. Palpation of the uterus as a firm
redness on the left breast, and the mother contracted ball
is diagnosed with mastitis. The mother 3. The saturation of more than one
asks the nurse about the condition. The peripad per hour
nurse should make which response? 4. Palpation of the fundus at the level of
1. "Mastitis usually involves both breasts." the umbilicus
2. "Mastitis can occur at any time during
breast-feeding." 3. The saturation of more than one peripad
3. "Mastitis usually is caused by wearing a per hour
supportive bra."
4. "Mastitis is most common for women 37. The nurse is providing instructions to a
who have breast-fed in the past." client who has been diagnosed with
mastitis. Which statement, if made by the
2. "Mastitis can occur at any time during client, indicates a need for further
breast-feeding." instructions?
1. "I need to wear a supportive bra to
34. The nurse is developing a plan of care for relieve the discomfort."
a client recovering from a cesarean 2. "I need to stop breast-feeding until this
delivery. Which action should the nurse condition resolves."
encourage the client to do to prevent 3. "I can use analgesics to assist in
thrombophlebitis? alleviating some of the discomfort."
1. Elevate her legs. 4. "I need to take antibiotics, and I should
2. Remain on bed rest. begin to feel better in 24 to 48 hours."
3. Ambulate frequently.
4. Apply warm, moist packs to the legs. 2. "I need to stop breast-feeding until this
condition resolves."
3. Ambulate frequently.
38. A postpartum client with deep vein
35. The nurse performs an assessment on a thrombosis is being treated with
client who is 4 hours postpartum. The anticoagulant therapy. The nurse
nurse notes that the client has cool, understands that the client's response to
clammy skin and is restless and treatment will be evaluated by regularly
excessively thirsty. assessing the client for which symptoms?
What immediate action should the nurse 1. Dysuria, ecchymosis, and vertigo
take? 2. Epistaxis, hematuria, and dysuria
1. Provide oral fluids and begin fundal 3. Hematuria, ecchymosis, and vertigo
massage. 4. Hematuria, ecchymosis, and epistaxis
2. Begin hourly pad counts and reassure
the client. 4. Hematuria, ecchymosis, and epistaxis
3. Elevate the head of the bed and assess
vital signs. 39. After surgical evacuation and repair of a
4. Assess for hypovolemia and notify the paravaginal hematoma, a client is
health care provider (HCP). discharged 3 days postpartum. The nurse
determines that the client needs further
4. Assess for hypovolemia and notify the discharge instructions when the client
health care provider (HCP). makes which statement?
1. "I will probably need my mother to help
me with housekeeping."
 2. "Because I am so sore, I will nurse the promote healing."
baby while lying on my side." 3. "I need to apply warm compresses to
3. "My husband and I will not have provide comfort."
intercourse until the stitches are healed." 4. "I need to isolate the infant for 48 hours
4. "The only medications I will take are after beginning the antibiotics."
prenatal vitamins and stool softeners."
4. "I need to isolate the infant for 48 hours
4. "The only medications I will take are after beginning the antibiotics."
prenatal vitamins and stool softeners."
43. A client has just had surgery to deliver a
40. The nurse is developing a plan of care for nonviable fetus resulting from abruptio
a postpartum client who was diagnosed placentae. As a result of the abruptio
with superficial venous thrombosis. The placentae, the client develops
nurse anticipates that which intervention disseminated intravascular coagulation
will be prescribed? (DIC) and is told about the complication.
1. Administration of anticoagulants The client begins to cry and screams,
2. Elevation of the affected extremity "God, just let me die now!" Which client
3. Ambulation eight to ten times daily problem should be the priority for the
4. Application of ice packs to the affected client at this time?
area 1. Lack of power about the situation
2. Grieving because of the loss of the
2. Elevation of the affected extremity baby
3. Lack of knowledge regarding what
41. A new mother received epidural occurred
anesthesia during labor and had a forceps 4. Concern about the loss of the baby and
delivery after pushing for 2 hours. At 6 personal health
hours postpartum her systolic blood
pressure has dropped 20 points, her 4. Concern about the loss of the baby and
diastolic blood pressure has dropped 10 personal health
points, and her pulse is 120 beats/min.
The client is anxious and restless. On 44. The rubella vaccine has been prescribed
further assessment, a vulvar hematoma is for a new mother. Which statement should
verified. After notifying the health care the postpartum nurse make when
provider, what is the nurse's next action? providing information about the vaccine to
1. Reassure the client. the client?
2. Monitor fundal height. 1. "You should avoid sexual intercourse
3. Apply perineal pressure. for 2 weeks after administration of the
4. Prepare the client for surgery. vaccine."
2. "You should not become pregnant for 2
4. Prepare the client for surgery. to 3 months after administration of the
vaccine."
42. The home care nurse visits a client who 3. "You should avoid heat and extreme
has delivered a healthy newborn infant via temperature changes for 1 week after
vaginal delivery. An episiotomy was administration of the vaccine."
performed, and the woman has developed 4. "You must sign an informed consent
a wound infection at the episiotomy site. because anaphylactic reactions can occur
The nurse provides instructions to the with the administration of this vaccine."
client regarding care related to the
infection. Which statement, if made by the 2. "You should not become pregnant for 2 to 3
mother, indicates a need for further months after administration of the vaccine."
instructions?
1. "I need to take the antibiotics as 45. The nursing student is assigned to care
prescribed." for a client in the postpartum unit. The
2. "I need to take warm sitz baths to coassigned nurse asks the student to
 identify the most objective method to 2. Retained placental fragments from delivery
assess the amount of lochial flow in the
client. Which statement, if made by the 48. The nurse is monitoring a postpartum
student, indicates an understanding of this client who is at risk of developing
method? postpartum endometritis. Which finding, if
1. "I can estimate the amount of blood noted during the first 24 hours after
loss by gauging the amount of staining on delivery, would support a diagnosis of
a perineal pad." postpartum endometritis?
2. "I should ask the client to keep a record 1. Abdominal tenderness and chills
and document every time the perineal pad 2. Increased perspiration and appetite
is changed." 3. Maternal oral temperature of 100.2° F
3. "I should weigh the perineal pad before 4. Uterus two fingerbreadths below
and after use and note the amount of time midline and firm
between each pad change."
4. "I can look at the perineal pad and 1. Abdominal tenderness and chills
gauge the amount of staining and relate it
to the amount of time between pad 49. Which nursing intervention would be most
changes." appropriate for a postpartum client with a
diagnosis of endometritis to facilitate
3. "I should weigh the perineal pad before and participation in newborn care?
after use and note the amount of time 1. Limit fluid intake.
between each pad change." 2. Maintain the client in a supine position.
3. Ask family members to care for the
46. The nurse in the postpartum unit is newborn.
observing the mother-infant bonding 4. Encourage the client to take pain
process in a client. Which observation, if medication as prescribed.
made by the nurse, indicates the potential
for a maladaptive interaction? 4. Encourage the client to take pain
1. The mother is observed talking to the medication as prescribed.
newborn.
2. The mother performs cord care for the 50. The nurse is caring for a client in the
newborn. postpartum period immediately after
3. The mother verbalizes discomfort with delivery. The nurse performs an
the new role of motherhood. assessment on the client and prepares to
4. The mother requests that the nurse assess uterine involution by taking which
feed the newborn because she is feeling action?
fatigued. 1. Monitoring the vital signs
2. Palpating the uterine fundus
4. The mother requests that the nurse feed 3. Auscultating the bowel sounds
the newborn because she is feeling fatigued. 4. Assessing the amount of drainage on
the peripad
47. The postpartum nurse is caring for a
woman who just delivered a healthy 2. Palpating the uterine fundus
newborn. The nurse should
be most concerned with the presence of 51. The nurse is assessing a client in the
subinvolution if which occurs? postpartum period and suspects the
1. The presence of afterpains presence of uterine atony. Which is
2. Retained placental fragments from the initial nursing action?
delivery 1. Massage the uterus until firm.
3. An oral temperature of 99.0° F following 2. Take the client's blood pressure.
delivery 3. Contact the health care provider (HCP).
4. Increased estrogen and progesterone 4. Assess the amount of drainage on the
levels as noted on laboratory analysis peripad.
 1. Massage the uterus until firm. 3. Cover the client with a warm blanket.

52. The postpartum unit nurse is developing a 55. The postpartum unit nurse has provided
plan of care for a first-time mother and information regarding performing a sitz
identifies the need for measures that will bath to a new mother after a vaginal
promote parent-infant bonding. Which delivery. The client demonstrates
measure should the nurse include in the understanding of the purpose of the sitz
plan? bath by stating that the sitz bath will
1. Use a low-pitched voice to speak to the promote which action?
infant. 1. Numb the tissue.
2. Encourage the mother to hold the infant 2. Stimulate a bowel movement.
when the infant cries. 3. Reduce the edema and swelling.
3. Encourage the parents to allow the 4. Assist in healing and provide comfort.
infant to sleep in the parental bed.
4. Encourage the mother to allow the 4. Assist in healing and provide comfort.
nursing staff to care for the infant during
her hospital stay until she is discharged. 56. A nurse is assessing the fundus in a
postpartum woman and notes that the
2. Encourage the mother to hold the infant uterus is soft and spongy and is not firmly
when the infant cries. contracted. The nurse should prepare to
implement which interventions? Select all
53. The postpartum unit nurse has provided that apply.
discharge instructions to a client planning 1. Massaging the uterus
to breast-feed her normal, healthy infant. 2. Pushing gently on the uterus
Which statement by the client indicates an 3. Assisting the woman to urinate
understanding of the instructions? 4. Rechecking the uterus in 1 hour
1. "If I experience any sweating during the 5. Checking for a distended bladder
night, I should call the health care 6. Calling the delivery room to schedule
provider." an abdominal hysterectomy
2. "If I have uterine cramping while breast- o 1. Massaging the uterus
feeding, I should contact the health care o 3. Assisting the woman to urinate
provider." o 5. Checking for a distended bladder
3. "If I'm still having bloody vaginal 57. A woman infected with the human
drainage in a week, I should contact the immunodeficiency virus (HIV) has given
health care provider." birth to a normal-appearing infant, and the
4. "If I notice any pain, redness, or nurse provides instructions about newborn
swelling in my breasts, I should contact infant care. Which statement by the
the health care provider." mother indicates a need for further
instruction?
4. "If I notice any pain, redness, or swelling in 1. "I'm going to breast-feed my baby
my breasts, I should contact the health care starting right away."
provider." 2. "I need to wash my hands before and
after bathroom use."
54. A client arrives at the postpartum unit after 3. "My baby needs to be on antiviral
delivery of her infant. On performing an medications for the next 6 weeks."
assessment, the nurse notes that the 4. "I am going to contact some support
client is shaking uncontrollably. Which groups listed in my take-home material to
nursing action would be appropriate? help me with everything I'll have to deal
1. Massage the fundus. with when I get home."
2. Contact the health care provider.
3. Cover the client with a warm blanket. 1. "I'm going to breast-feed my baby starting
4. Place the client in Trendelenburg's right away."
position.
58. The clinic nurse is performing an 3. A mother who gave birth vaginally to a 3200
assessment on a client who is 6 days gram infant
postpartum. When assessing involution,
the nurse expects the uterine fundus to be 61. A postpartum unit nurse is preparing to
located at which area? care for a client who has just delivered a
healthy newborn. In the immediate
postpartum period what is the
recommended frequency for the nurse to
assess the client's vital signs?
1. Every hour for the first 2 hours and then
every 4 hours
2. Every 30 minutes during the first hour
and then every hour for the next 2 hours
3. Every 5 minutes for the first 30 minutes
and then every hour for the next 4 hours
4. Every 15 minutes during the first hour
and then every 30 minutes for the next 2
hours
1. A
2. B
4. Every 15 minutes during the first hour and
3. C then every 30 minutes for the next 2 hours
4. D
62. The postpartum unit nurse is performing
4. D
an assessment on a client who is at risk
for thrombophlebitis. Which nursing action
59. A client with known cardiac disease has is indicated in assessing for
been admitted to the postpartum care unit thrombophlebitis?
after an uneventful delivery. The unit 1. Palpate for pedal pulses.
nurse instructs the client to use the call
2. Ask the client about pain in the calf
button for assistance whenever she needs area.
to get out of bed or wishes to care for her 3. Assess for the presence of vaginal
infant. Which postpartum complication is hematoma.
the nurse most concerned about for this
4. Ask the client to ambulate and assess
client? for the presence of pain.
1. Postpartum infection
2. Maternal attachment 2. Ask the client about pain in the calf area.
3. Maternal overexertion
4. Postpartum newborn-mother bonding
63. The rubella vaccine is prescribed to be
administered to a client 2 days after
3. Maternal overexertion
delivery of her child. The nurse preparing
to administer the vaccine develops a list of
60. A postpartum care unit nurse is reviewing the potential risks associated with this
the records of 4 new mothers admitted to
vaccine. The nurse reviews the list with
the unit. The nurse determines that which the client and cautions the client to avoid
mother would be least likely at risk for
which situation?
developing a puerperal infection? 1. Sunlight for 3 days
1. A mother who had ten vaginal exams 2. Scratching the injection site
during labor 3. Pregnancy for 2 to 3 months after the
2. A mother with a history of previous vaccination
puerperal infections 4. Sexual intercourse for 2 to 3 months
3. A mother who gave birth vaginally to a after the vaccination
3200 gram infant
4. A mother who experienced prolonged 3. Pregnancy for 2 to 3 months after the
rupture of the membranes vaccination
64. On the second postpartum day, a woman breast.
complains of burning on urination, 3. The mother is breast-feeding the infant
urgency, and frequency of urination. A with the infant's head turned toward her
urinalysis is done, and the results indicate breast and the body flat in her arms; the
the presence of a urinary tract infection. mother has sore nipples, and the infant
The nurse instructs the new mother has a suck blister.
regarding measures to take for treatment 4. The mother is breast-feeding with the
of the infection. Which statement, if made infant in a tummy-to-tummy position
by the mother, would indicate a need for without signs of cracked nipples; the baby
further instructions? demonstrates bursts of sucking, followed
1. "I need to urinate frequently throughout by a pause and swallow.
the day."
2. "The prescribed medication must be 4. The mother is breast-feeding with the infant
taken until it is finished." in a tummy-to-tummy position without signs of
3. "My fluid intake should be increased to cracked nipples; the baby demonstrates
at least 3000 mL daily." bursts of sucking, followed by a pause and
4. "Foods and fluids that will increase swallow.
urine alkalinity should be consumed."
67. The nurse who is employed in a prenatal
4. "Foods and fluids that will increase urine clinic is performing prenatal assessments
alkalinity should be consumed." on clients who are in their first trimester of
pregnancy. The nurse is concerned with
65. A pregnant woman who is infected with identifying clients who may be at risk for
the human immunodeficiency virus (HIV) the development of postpartum
delivers a newborn infant, and the nurse complications. Which client would be at
provides instructions to help the mother the lowest risk for development of
regarding care of the infant. Which postpartum thromboembolic disorders?
statement by the client would indicate 1. A 39-year-old woman who reports that
the need for further instructions? she smokes
1. "I will be sure to wash my hands before 2. A 26-year-old woman with a family
and after bathroom use." history of thrombophlebitis
2. "I need to breast-feed, especially for the 3. A 37-year-old woman in her fourth
first 6 weeks postpartum." pregnancy who is overweight
3. "Support groups are available to assist 4. A 22-year-old woman with a first
me with understanding my diagnosis of pregnancy who states that oral
HIV." contraceptives taken in the past have
4. "My newborn infant should be on caused thrombophlebitis
antiviral medications for the first 6 weeks
after delivery." 2. A 26-year-old woman with a family history
of thrombophlebitis
2. "I need to breast-feed, especially for the
first 6 weeks postpartum." 68. The nurse has provided instructions for a
postpartum client at risk for thrombosis
66. The home care nurse's assignment is to regarding measures to prevent its
visit a new mother at home 24 to 48 hours occurrence. Which statement, if made by
after discharge. What should the nurse the client, indicates a need for further
expect to note in a healthy mother who is education?
breast-feeding her newborn infant? 1. "I should apply my antiembolism
1. The mother has cracked nipples and stockings after breakfast."
feeds the infant with a supplemental 2. "I should avoid prolonged standing or
bottle. sitting in one position."
2. The mother complains of breast 3. "I should perform regularly scheduled
engorgement, and the infant exercise such as walking."
demonstrates difficulty in latching onto the 4. "I should avoid using pillows under my
 knees to prevent pressure in the back of Ringer's solution (D5LR) with 20 milliunits
my knee area." of oxytocin (Pitocin) infusing at 125 mL/hr.
2. A 12-hour post–cesarean section
1. "I should apply my antiembolism stockings delivery of a gravida 3, para 3, who
after breakfast." reports a return of feeling in her lower
extremities as well as a sensation of
69. The discharge nurse is discussing mastitis wetness underneath her buttocks.
with a postpartum client. Which statement 3. A 48-hour post–cesarean section
made by the client indicates a need for delivery of a gravida 1, para 1, who
further instruction? reports not yet having a bowel movement
1. "If I develop a hot, reddened, triangle- since delivery and requests a stool
shaped area on my breast, I should softener.
contact my health care provider." 4. A 24-hour post–vaginal delivery of a
2. "Antibiotics, rest, warm compresses, gravida 4, para 4, who is complaining of
and adequate fluid intake are all important abdominal cramping after nursing her
for the treatment of mastitis." baby and requesting ibuprofen (Motrin).
3. "If I develop a fever, chills, or body o 2. A 12-hour post–cesarean section
aches at any time after discharge, I should delivery of a gravida 3, para 3, who
stop breast-feeding immediately." reports a return of feeling in her lower
4. "I may develop mastitis if I wear extremities as well as a sensation of
underwire bras, experience excessive wetness underneath her buttocks.
o 4. A 24-hour post–vaginal delivery of a
fatigue, or suddenly decrease the number
gravida 4, para 4, who is complaining
of feedings." of abdominal cramping after nursing
her baby and requesting ibuprofen
3. "If I develop a fever, chills, or body aches at (Motrin).
any time after discharge, I should stop breast- o 1. 1. An 8-hour post–vaginal delivery
feeding immediately." gravida 2, para 2 client who is
scheduled for a bilateral tubal ligation
70. On assessment of a client who is 30 at 1200 today and has a continuous
minutes into the fourth stage of labor, the peripheral intravenous (IV) solution of
nurse finds the client's perineal pad 5% dextrose in lactated Ringer's
saturated in blood and blood soaked into solution (D5LR) with 20 milliunits of
the bed linen under the client's buttocks. oxytocin (Pitocin) infusing at 125
mL/hr.
Which is the nurse's initial action?
o 3. 3. A 48-hour post–cesarean section
1. Call the health care provider. delivery of a gravida 1, para 1, who
2. Assess the client's vital signs. reports not yet having a bowel
3. Gently message the uterine fundus. movement since delivery and requests
4. Administer a 300-mL bolus of a 20 a stool softener.
units/L oxytocin (Pitocin) solution. 72. A client who is a gravida III, para III had a
cesarean section 1 day ago. She is being
3. Gently message the uterine fundus. treated prophylactically for endometritis.
She is complaining of abdominal cramping
71. After receiving report at the beginning of at a level of 6 on pain level scale of 1 to
the 0700 shift, the nurse must decide in 10 (with 10 being the greatest amount of
what order the clients should be pain) and fears having her first bowel
assessed. How would the nurse plan movement. These medications are
assessments? Arrange the clients in the prescribed and due now. Based
order that they should be assessed. All on priority, in which order should the
options must be used. nurse administer the
1. An 8-hour post–vaginal delivery gravida medications? Arrange the medications
2, para 2 client who is scheduled for a in the order that they should be
bilateral tubal ligation at 1200 today and administered. All options must be
has a continuous peripheral intravenous used.
(IV) solution of 5% dextrose in lactated 1. Prenatal vitamin 1 tablet orally daily
 2. Docusate sodium (Colace) 100 mg 2. "You should avoid sexual intercourse
orally for 2 weeks after the administration of the
3. Ketorolac (Toradol) 30 mg by vaccine."
intravenous push over 3 minutes 3. "You should not become pregnant for 1
4. Ampicillin sodium (Ampicillin) 1 g to 3 months after the administration of the
intravenous (IV) piggyback over 60 vaccine."
minutes 4. "You should avoid heat and extreme
o 3. Ketorolac (Toradol) 30 mg by temperature changes for a week after the
intravenous push over 3 minutes administration of the vaccine."
o 4. Ampicillin sodium (Ampicillin) 1 g
intravenous (IV) piggyback over 60 3. "You should not become pregnant for 1 to 3
minutes months after the administration of the
o 2. Docusate sodium (Colace) 100 mg vaccine."
orally
o 1. Prenatal vitamin 1 tablet orally daily
76. A nurse has just received an intershift
73. A nurse is checking lochia discharge in a
report. After reviewing the client
woman in the immediate postpartum
assignment and the appropriate medical
period. The nurse notes that the lochia is
records, the nurse determines that which
bright red and contains some small clots.
client is most at risk for developing
Based on this data, the nurse should
postdelivery endometritis?
make which interpretation?
1. A primigravida with a normal
1. The client is hemorrhaging.
spontaneous vaginal delivery
2. The client needs to increase oral fluids.
2. A gravida II who delivered vaginally
3. The client is experiencing normal lochia
following an 18-hour labor
discharge.
3. A client experiencing an elective
4. The client's health care provider needs
cesarean delivery at 38 weeks' gestation
to be notified of the finding.
4. An adolescent experiencing an
3. The client is experiencing normal lochia
emergency cesarean delivery for fetal
discharge. distress

4. An adolescent experiencing an emergency

74. A postpartum woman with mastitis in the
cesarean delivery for fetal distress
right breast complains that the breast is
too sore for her to breast-feed her infant.
77. A nurse provides a list of discharge
The nurse should tell the client to
instructions to a client who has delivered a
implement which measure?
healthy newborn by cesarean delivery.
1. Pump both breasts and discard the
Which statement by the client indicates
milk.
the need for further teaching?
2. Bottle-feed the infant on a temporary
1. "I can begin abdominal exercises
basis.
immediately."
3. Breast-feed from the left breast and
2. "I need to notify the health care
gently pump the right breast.
provider if I develop a fever."
4. Stop breast-feeding from both breasts
3. "I can't lift anything heavier than my
until this condition resolves.
newborn for at least 2 weeks."
3. Breast-feed from the left breast and gently
4. "I need to turn on my side and push up
pump the right breast. with my arms to get out of bed."

1. "I can begin abdominal exercises

75. The rubella vaccine has been prescribed
immediately."
for a new mother. Which statement should
the postpartum nurse make when
78. A nurse is caring for a client who has just
providing information about the vaccine to
delivered a newborn following a
the client?
pregnancy with a placenta previa. When
1. "You will need a second vaccination at
reviewing the plan of care, the nurse
your 6-week postpartum visit."
 should prepare to monitor the client for 3. 500
which risk that is associated with placenta
previa? 82. The postpartum client asks the nurse
1. Infection about the occurrence of afterpains. The
2. Hemorrhage nurse informs the client that afterpains will
3. Chronic hypertension be especially noticeable during which
4. Disseminated intravascular coagulation activity?
1. Ambulating
2. Hemorrhage 2. Breast-feeding
3. Taking sitz baths
79. The nurse is preparing to perform a fundal 4. Arriving home and activities are
assessment on a postpartum client. The increased
nurse understands that which is
the initial nursing action when performing 2. Breast-feeding
this assessment?
1. Ask the client to turn on her side. 83. The nursing instructor is reviewing the
2. Ask the client to urinate and empty her plan of care with a student regarding care
bladder. of a postpartum client. The instructor asks
3. Massage the fundus gently before the nursing student about the taking-in
determining the level of the fundus. phase according to Rubin's phases of
4. Ask the client to lie flat on her back, regeneration and the client behaviors that
with her knees and legs flat and straight. are most likely to occur during this
phase. Which response made by the
2. Ask the client to urinate and empty her student indicates an understanding of this
bladder. phase?
1. "The client would be independent."
80. The nurse is preparing to care for a client 2. "The client initiates activities on her
in the immediate postpartum period who own."
has just delivered a healthy newborn. How 3. "The client participates in mothering
often should the nurse plan to take the tasks."
client's vital signs? 4. "The client is self-focused and talks to
1. Hourly for the first 2 hours and then others about labor."
every 4 hours
2. 30 minutes during the first hour and 4. "The client is self-focused and talks to
then every hour for the next 2 hours others about labor."
3. 5 minutes for the first 30 minutes and
then every hour for the next 4 hours 84. The nurse is teaching a new mother how
4. 15 minutes during the first hour and to care for her newborn. The nurse notes
then every 30 minutes for the next 2 hours that the client is very fearful and reluctant
to handle the newborn and notes that this
4. 15 minutes during the first hour and then is the client's first child. Which nursing
every 30 minutes for the next 2 hours intervention is least appropriate in
assisting the promotion of mother-infant
81. The nurse is providing nutritional interaction and bonding?
counseling to a new mother who is breast- 1. Accepting the client's feelings
feeding her newborn. The nurse should 2. Acknowledging the client's
instruct the client that her calorie needs apprehension
should increase by approximately how 3. Assisting the client with giving the baths
many calories a day? to allow her to become more at ease
1. 100 4. Leaving the infant with the client so that
2. 300 she will be required to provide the care
3. 500
4. 1000 4. Leaving the infant with the client so that she
will be required to provide the care
85. The nurse is assigned to care for a client 4. "I need to take antibiotics, and I should
who has chosen to formula-feed her begin to feel better in 24 to 48 hours."
infant. The nurse should plan to provide
which instruction to the client? 2. "I need to stop breast-feeding until this
1. Apply a heating pad to breasts for condition resolves."
comfort.
2. Wear a breast shield to correct nipple 89. A nurse is monitoring the client for signs
inversion. of postpartum depression. Which would
3. Wear a supportive brassiere indicate the need for further assessment
continuously for 72 hours. related to this form of depression?
4. Use the manual breast pump provided 1. The client is caring for the infant in a
to express milk. loving manner.
2. The client demonstrates an interest in
3. Wear a supportive brassiere continuously the surroundings.
for 72 hours. 3. The client constantly complains of
tiredness and fatigue.
86. The postpartum client who had a vaginal 4. The client looks forward to visits from
delivery of a healthy newborn has a the father of the newborn.
prescription for a sitz bath. The nurse
should tell the client that the sitz bath will 3. The client constantly complains of tiredness
provide which effect? and fatigue.
1. Numb the tissue.
2. Stimulate a bowel movement. 90. The nurse caring for a client with a
3. Reduce the edema and swelling. diagnosis of subinvolution should
4. Promote healing and provide comfort. understand that which is a primary cause
of this diagnosis?
4. Promote healing and provide comfort. 1. Afterpains
2. Increased estrogen levels
87. A nurse is monitoring a new mother in the 3. Increased progesterone levels
fourth stage of labor for signs of 4. Retained placental fragments from
hemorrhage. Which indicates delivery
an early sign of excessive blood loss?
1. A temperature of 100.4º F 4. Retained placental fragments from delivery
2. An increased pulse rate of 88 to 102
beats/min 91. The nurse has determined that a
3. A blood pressure change from 130/88 postpartum client has physical findings
to 124/80 mm Hg consistent with uterine atony. The nurse
4. An increase in the respiratory rate from should plan to take which action first?
18 to 22 breaths/min 1. Massage the uterus until firm.
2. Take the client's blood pressure.
2. An increased pulse rate of 88 to 102 3. Ask the client about the presence of
beats/min pain.
4. Recheck the amount of drainage on the
88. A nurse is providing instructions to a client peripad.
who has been diagnosed with mastitis.
Which statement made by the client 1. Massage the uterus until firm.
indicates a need for further teaching?
1. "I need to wear a supportive bra to 92. When planning care for a postpartum
relieve the discomfort." client that plans to breast-feed her infant,
2. "I need to stop breast-feeding until this which important piece of information
condition resolves." should the nurse include in the teaching
3. "I can use analgesics to assist in plan to prevent the development of
alleviating some of the discomfort." mastitis?
1. Offer only one breast at each feeding.
 2. Massage distended areas as the infant o 3. Feed the infant at least every 2
nurses. hours for 15 to 20 minutes on each
3. Cleanse nipples with a mild side.
antibacterial soap before and after infant o 4. Apply moist heat to both breasts for
about 20 minutes before a feeding.
feedings.
o 5. Massage the breasts gently during
4. Express and discard milk from the a feeding, from the outer areas to the
affected breast at the first signs of nipples.
mastitis. 95. On the second postpartum day, a client
complains of burning, urgency, and
2. Massage distended areas as the infant frequency of urination. A urinalysis is
nurses.
obtained, and the results indicate the
presence of a urinary tract infection.
93. Which instructions should a nurse provide Which measures should the nurse instruct
to a client following delivery regarding the client to take regarding the prevention
care of the episiotomy site to prevent and treatment of the infection? Select all
infection? Select all that apply. that apply.
1. Report a foul-smelling discharge. 1. Urinate frequently throughout the day.
2. Take a warm sitz baths three times a 2. Wipe the perineal area from front to
day. back after urinating.
3. Change the perineum pads three times 3. Fluid intake should be increased to at
a day. least 3000 mL/day.
4. Use warm water to rinse the perineum 4. Prescribed medication must be taken
after elimination. until it is completed.
5. Wipe the perineum from front to back 5. Foods and fluids that will increase urine
after voiding and defecation. alkalinity should be consumed.
o 1. Report a foul-smelling discharge. o 1. Urinate frequently throughout the
o 2. Take a warm sitz baths three times day.
a day. o 2. Wipe the perineal area from front to
o 4. Use warm water to rinse the back after urinating.
perineum after elimination. o 3. Fluid intake should be increased to
o 5. Wipe the perineum from front to at least 3000 mL/day.
back after voiding and defecation. o 4. Prescribed medication must be
94. A nurse visits a client at home who taken until it is completed.
delivered a healthy newborn 2 days ago.
The client is complaining of breast
discomfort. The nurse notes that the client
is experiencing breast engorgement.
Which instructions should the nurse
provide to the client regarding relief of the
engorgement? Select all that apply.
1. Wear a supportive bra between
feedings.
2. Avoid breast-feeding during the time of
breast engorgement.
3. Feed the infant at least every 2 hours
for 15 to 20 minutes on each side.
4. Apply moist heat to both breasts for
about 20 minutes before a feeding.
5. Massage the breasts gently during a
feeding, from the outer areas to the
nipples.
o 1. Wear a supportive bra between
feedings.