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Postpartum 2
Nclex ?'s
| Question | Answer |
|---|---|
| When checking a woman’s fundus 20 hours after cesarean birth of her third baby, the nurse finds her fundus at the level of her umbilicus, firm, and midline. The appropriate nursing action related to this assessment is to: Document the normal assessment | Document the normal assessment |
| A woman who is 18 hours postpartum says she is having “hot flashes” and “sweats all the time.” The appropriate nursing response is to: Report her signs and symptoms of hypovolemic shock Tell her that her body is getting rid of unneeded fluid Notify he | Tell her that her body is getting rid of unneeded fluid |
| A woman who is 3 hours postpartum has had difficulty in urinating. She finally urinates 100 mL. The initial nursing action is to: Insert an indwelling catheter Have her drink additional fluids Assess the height of her fundus Chart the urination amo | Assess the height of her fundus |
| When teaching the postpartum woman about peripads, the nurse should tell her that: She can change to tampons when the initial perineal soreness goes away Pads having cold packs within them usually hold more lochia than regular pads Blood-soaked pads mu | The pads should be applied and removed in a front-to-back direction |
| A young mother is excited about her first baby. Choose the best teaching to help her obtain adequate rest after discharge. Plan to sleep or rest any time the infant sleeps Do all house cleaning while the infant sleeps Cook several meals at once and fr | Plan to sleep or rest any time the infant sleeps |
| Choose the best independent nursing action to aid episiotomy healing in the woman who is 24 hours postpartum. Antibiotic cream applications to the area three times each day Squirting warm water over the perineum after voiding or stooling Maintaining c | Squirting warm water over the perineum after voiding or stooling |
| The nurse places one hand above the symphysis pubis during uterine massage to: Make the massage more comfortable for the woman Increase the effectiveness of the procedure Help prevent the uterus from inverting Help determine the firmness of the uterus | Help prevent the uterus from inverting |
| A woman who is 4 hours postpartum ambulates to the bathroom and suddenly has a large gush of lochia rubra. The nurse’s first action should be to: Determine the height of the fundus and if the bleeding slows to normal or remains large Observe vital sig | Determine the height of the fundus and if the bleeding slows to normal or remains large |
| To help the postpartum woman avoid constipation, the nurse should teach her to: Avoid intake of foods such as milk, cheese, or yogurt Take a laxative for the first 3 postpartum days Drink at least 1600 mL of non-caffeinated fluids daily Limit her walk | Drink at least 1600 mL of non-caffeinated fluids daily |
| Choose the sign or symptom that the new mother should be taught to report. Occasional uterine cramping when the infant nurses Oral temperature that is 37.20 C (990 F) in the morning Descent of the fundus one fingerbreadth each day Reappearance of red | Reappearance of red lochia after it changes to serous |
| Twelve hours after birth, a mother lies in bed resting. Although she has only one more day in the hospital, she does not ask about her baby or provide any care. What is the probable reason for her behavior? She is still in the taking-in phase of matern | She shows behaviors that may lead to postpartum depression |
| At her 6-week checkup, a woman expresses frustration because she is “still fat.” the appropriate initial nursing response is to: Explain that safe weight loss will take approximately 6 to 12 months Reassure her that she does not look fat to others Pro | Explain that safe weight loss will take approximately 6 to 12 months |
| A new father is reluctant to “spoil” his newborn by picking her up when she cries. The best nursing response is to: Teach him that she will eventually stop crying if he waits Take the baby to the nursery to allow the parents to rest Pick the baby up a | Tell the father that the baby cries to communicate a need |
| A newborn is in the crib in his mother’s room. The teenaged mother is watching TV. When the nurse notes that the baby is awake and quiet, the best nursing action is to: Pick the baby up and point out his alert behaviors to the mother Tell the mother | Pick the baby up and point out his alert behaviors to the mother |
| The nurse can encourage the parents to care for their infant by: Staying out of he room for as long as possible Having the grandmother nearby as a backup Giving positive feedback when they provide care Correcting their performance whenever they make a | Giving positive feedback when they provide care |
| The nurse notes that a woman has excess lochia 2 hours after vaginal birth of an 8 lb baby. The priority nursing action is to: Catheterize her to check urine output Check her blood pressure, pulse, and respirations Assess the firmness of her uterus N | Assess the firmness of her uterus |
| Choose the signs and symptoms that suggest postpartum hemorrhage causing a hematoma. Rectal pain accompanied by a rising pulse Cramping accompanied by a steady trickle of blood Soft uterine fundus and a falling blood pressure Heavy lochia accompanied | Rectal pain accompanied by a rising pulse |
| One hour after a woman gives birth vaginally, the nurse notes that her fundus is firm, 2 fingerbreadths above the umbilicus, and deviated to the right. Lochia rubra is moderate. Her perineum is slightly edematous, with no bruising; an ice pack is in pla | Have the woman empty her bladder |
| What drug should be readily available when a woman is receiving heparin therapy? Vitamin K Methylergonovine Ferrous sulfate Protamine sulfate | Protamine sulfate |
| The nurse’s initial response if a pulmonary embolism is suspected should be to: Start a second intravenous (IV) line and prepare for transfusion Raise the head of the bed and administer oxygen Insert a catheter to monitor urine output Lower the head o | Raise the head of the bed and administer oxygen |
| A woman has an 8 lb, 9 oz baby after an 18 hour labor that required a vacuum extraction. Her membranes have been ruptured for 15 hours. Based on these facts, client teaching should emphasize: Reporting foul-smelling lochia and fever Delaying intercour | Reporting foul-smelling lochia and fever |
| Postpartum teaching related to urinary health should emphasize: Drinking any type of fluid whenever thirsty Allowing the bladder to fill to promote emptying Cleansing the perineum in a front-to-back direction Eating two servings of acidic fruits or ve | Cleansing the perineum in a front-to-back direction |
| A new father tells a nurse friend that his wife is agitated and acting bizarrely. She says she hears voices. Her baby is 2 weeks old. The father is concerned about the care the mother is giving the baby. The nurse should: Tell the father that this is | Tell the father to call the physician immediately and not to leave the woman alone with the baby |
| A breastfeeding woman develops mastitis. She tells the nurse that she will feed her baby formula instead of breastfeeding until the infection is healed. The best nursing response is that: Emptying the breast is important to prevent an abscess A tight | Emptying the breast is important to prevent an abscess |
| A woman tells you she has been teary for most of the 2 weeks since the birth of her baby. Although the infant appears to be cared for appropriately, the mother states that she feels too tired to spend as much time with him as she should. She has lost he | Listen to her feelings carefully and then acknowledge that something is wrong |
Created by:
L.moore
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