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Maternity Final
pretest questions
| Question | Answer |
|---|---|
| The nurse is assessing a client 24 hours after delivery and finds the fundus to be slightly boggy and two centimeters above the umbilicus. What should be the priority nursing intervention? | After having the patient void, gently massage the fundus until firm. |
| A new mother complains of 'afterpains.' The nurse's first action should be to do which of the following? | administer an analgesic |
| The nurse is caring for a woman who gave birth to a daughter yesterday, but greatly desired a son. Today she seems withdrawn, staying in bed and staring at the wall. What is the most appropriate intervention? | encourage the mother to verbalize her disappointment |
| The nurse is preparing to instruct a new mother about resuming sexual intercourse postpartum. The nurse should include which of the following in the teaching plan? | Wait until episiotomy is healed and lochia has stopped before resuming intercourse AND a water soluble lube may be necessary |
| The nurse is caring for a client who has decided not to breastfeed. What should the nurse include in client teaching to promote lactation suppression? | Apply ice bag AND bind the breasts |
| A client has a temperature of 100.2 F four hours after delivery. What is the appropriate action for the nurse to take? | do nothing since this is an expected finding at this time |
| A client delivered 90 minutes ago. She is alert and physically active in the bed. She stated that she needs to go to the bathroom. What is the nurse's most appropriate response? | "I'll walk you to the bathroom and stay with you. |
| 36 yo woman, gravida 6 para 6, delivered a 7 lb14 oz girl at term after an eight hour labor, vital are stable, lochia is bright red, heavy, and contains some clots; some half dollar size. The nurse would consider the client at risk for uterine atony why? | grandmultiparity |
| nurse massaged boggy fundus, but she continues to pass several large clots and bright red lochia. The uterine fundus remains boggy and fundal massage and Pitocin aren't successful. What med will be prescribed next? | Carboprost (Prostin 15-M or Hemabate) |
| A new mother with mastitis is concerned about breastfeeding while she has an active infection. How should the nurse respond? | the organisms that cause mastitis are not passed through milk |
| If the nurse suspects a uterine infection in the postpartum client, the nurse should make which priority assessment? | odor of lochia |
| A postpartum pt develops a temp during her postpartum course. Which temp measurement indicates to the nurse the presence of postpartum infection? | 100.6 F at 48 postpartum and continues into the third day (should lower after day 2) |
| Which sign of thrombophlebitis should the nurse instruct the postpartal client to look for when at home after discharge from the hospital? | localized posterior leg tenderness, heat, and swelling |
| Which instruction should the nurse include in the discharge teaching to assist the postpartal client to recognize early signs of complications? | notify health care provider of increased lochia or bright red bleeding |
| At two days old, the nurse hears a murmur over the right and left auricles of the newborn's heart. The nurse concludes that this may represent patency of which structure> | foramen ovale |
| The maternal newborn nurse formulates which nursing goal for a newborn in transition within the first few hours after birth? | to identify actual and potential problems that may require immediate or emergency attention |
| The nurse conducts a neurological assessment of the newborn. Which indicates need for further evaluation? | Asymmetrical fine jumping movement of the leg and arm muscles AND muscle flaccidity not relieved by holding the newborn AND weak and ineffective sucking movements |
| Most newborns void in the first 24 hours after birth. The nurse interprets that which of the following is responsible for the reddish stain, sometimes called "red brick dust spots" or "brick deposits" on the newborns diaper? | uric acid crystal in the urine |
| A nurse providing care to a newborn would use which concept underlying adaption of the newborn's immune system when planning nursing care? | The newborn is unable to limit invading organisms at their point of entry |
| The nurse who is trying to prevent heat loss in the newborn recalls that which physical characteristics serve to increase a newborn's loss of heat? | blood vessel dilation and reddened skin AND limited subcutaneous fat AND larger body surface related to that of an adult |
| A postpartal client is bottle feeding her newborn. The nurse should teach the client to take which actions when the baby regurgitates small amounts of formula. | recognize this is a normal occurrence AND understand that this may result from overfeeding |
| the client who experienced postpartal demise states, 'Sometimes I feel like I have left my baby somewhere, and I can't remember where she is. Then I remember she that she isn't alive' The nurse interprets that this client is experiencing what? | search and yearning |
| The father of a stillborn infant tells the nurse he wants to hold the child. What is the nurse's best response? | dress the infant in a tshirt and diaper and let him hold the infant |
| The nurse determines that teaching about SIDS has been effective when the client makes which statement? | No definite cause of death is found at autopsy |
| The nurse interprets which of the following as somatic complaints of a postpartal woman who is grieving for her deceased infant? | Heaviness in the chest and fatigue AND weight loss and decreased appetite |
| The client being seen for a postpartal exam after delivering a still born girl six weeks ago asks the nurse, "When will i feel normal again?" The nurse's reply reflects the understanding that grief work takes approximately how long? | about one year |
| The maternal newborn nurse interprets the anticipatory grieving is likely to occur in a client who has experienced which of the following situations? | fetal anomaly identified during pregnancy |
| Which of the following tokens of remembrance would be appropriate for the nurse to provide to parents who are grieving the death of an infant? | lock of hair, footprints |
| The family is experienced a fetal loss. Which statement indicates that the nurse's teaching about family involvement in the birthing process needs clarification? | We should have the funeral through the mortuary the hospital uses |
Created by:
tabithadaniels