Maternal & Child Health Nursing NCLEX part 6

  Maternal & Child Health Nursing NCLEX part 6

 

 

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Postpartum Period:

1. The fundus of the uterus is expected to go down normally postpartally about __ cm per day.

 

A. 1.0 cm

B. 2.0 cm

C. 2.5 cm

D. 3.0 cm

 

2. The lochia on the first few days after delivery is characterized as

 

A. Pinkish with some blood clots

B. Whitish with some mucus

C. Reddish with some mucus

D. Serous with some brown tinged mucus

 

3. Lochia normally disappears after how many days postpartum?

 

A. 5 days

B. 7-10 days

C. 18-21 days

D. 28-30 days

 

4. After a Rh(-) mother has delivered her Rh (+) baby, the mother is given RhoGam. This is done in order to:

 

A. Prevent the recurrence of Rh(+) baby in future pregnancies

B. Prevent the mother from producing antibodies against the Rh(+) antigen that she may have gotten when she delivered to her Rh(+) baby

C. Ensure those future pregnancies will not lead to maternal illness

D. To prevent the newborn from having problems of incompatibility when it breastfeeds

 

5. To enhance milk production, a lactating mother must do the following interventions EXCEPT:

 

A. Increase fluid intake including milk

B. Eat foods that increase lactation which is called galactagogues

C. Exercise adequately like aerobics

D. Have adequate nutrition and rest

 

6. The nursing intervention to relieve pain in breast engorgement while the mother continues to breastfeed is

 

A. Apply cold compress on the engorged breast

B. Apply warm compress on the engorged breast

C. Massage the breast

D. Apply analgesic ointment

 

7. A woman who delivered normally per vaginam is expected to void within ___ hours after delivery.

 

A. 3 hrs

B. 4 hrs.

C. 6-8 hrs

D. 12-24 hours

 

8. To ensure adequate lactation the nurse should teach the mother to:

 

A. Breastfeed the baby on self-demand day and night

B. Feed primarily during the day and allow the baby to sleep through the night

C. Feed the baby every 3-4 hours following a strict schedule

D. Breastfeed when the breast are engorged to ensure adequate supply

 

9. An appropriate nursing intervention when caring for a postpartum mother with thrombophlebitis is:

 

A. Encourage the mother to ambulate to relieve the pain in the leg

B. Instruct the mother to apply elastic bondage from the foot going towards the knee to improve venous return flow

C. Apply warm compress on the affected leg to relieve the pain

D. Elevate the affected leg and keep the patient on bedrest

 

10. The nurse should anticipate that hemorrhage related to uterine atony may occur postnatally if this condition was present during the delivery:

 

A. Excessive analgesia was given to the mother

B. Placental delivery occurred within thirty minutes after the baby was born

C. An episiotomy had to be done to facilitate delivery of the head

D. The labor and delivery lasted for 12 hours

 

11. According to Rubin’s theory of maternal role adaptation, the mother will go through 3 stages during the postpartum perioD. These stages are:

 

A. Going through, adjustment period, adaptation period

B. Taking-in, taking hold and letting-go

C. Attachment phase, adjustment phase, adaptation phase

D. Taking-hold, letting-go, attachment phase

 

12. The neonate of a mother with diabetes mellitus is prone to developing hypoglycemia because:

 

A. The pancreas is immature and unable to secrete the needed insulin

B. There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin

C. The baby is reacting to the insulin given to the mother

D. His kidneys are immature leading to a high tolerance for glucose

 

13. Which of the following is an abnormal vital sign in postpartum?

 

A. Pulse rate between 50-60/min

B. BP diastolic increase from 80 to 95mm Hg

C. BP systolic between 100-120mm Hg

D. Respiratory rate of 16-20/min

 

14. The uterine fundus right after delivery of placenta is palpable at

 

A. Level of Xyphoid process

B. Level of umbilicus

C. Level of symphysis pubis

D. Midway between umbilicus and symphysis pubis

 

15. A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has a saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as:

 

A. Excessive

B. Heavy

C. Light

D. Scanty

 

16. In a woman who is not breastfeeding, menstruation usually occurs after how many weeks?

 

A. 2-4 weeks

B. 6-8 weeks

C. 6 months

D. 12 months

 

17. The following are nursing measures to stimulate lactation EXCEPT

 

A. Frequent regular breastfeeding

B. Breast pumping

C. Breast massage

D. Application of cold compress on the breast

 

18. When the uterus is firm and contracted after delivery but there is vaginal bleeding, the nurse should suspect

 

A. Laceration of soft tissues of the cervix and vagina

B. Uterine atony

C. Uterine inversion

D. Uterine hypercontractility

 

19. The following are interventions to make the fundus contract postpartally EXCEPT

 

A. Make the baby suck the breast regularly

B. Apply ice cap on fundus

C. Massage the fundus vigorously for 15 minutes until contracted

D. Give oxytocin as ordered

 

20. The following are nursing interventions to relieve episiotomy wound pain EXCEPT

 

A. Giving analgesic as ordered

B. Sitz bath

C. Perineal heat

D. Perineal care

 

21. Postpartum blues is said to be normal provided that the following characteristics are present. These are

 

1. Within 3-10 days only;

2. Woman exhibits the following symptoms- episodic tearfulness, fatigue, oversensitivity, poor appetite;

3. Maybe more severe symptoms in primipara

 

A. All of the above

B. 1 and 2

C. 2 only

D. 2 and 3

 

22. The neonatal circulation differs from the fetal circulation because

 

A. The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is mixed blooD.

B. The blood at the left atrium of the fetal heart is shunted to the right atrium to facilitate its passage to the lungs

C. The blood in the left side of the fetal heart contains oxygenated blood while the blood on the right side contains unoxygenated blooD.

D. None of the above

 

23. The normal respiration of a newborn immediately after birth is characterized as:

 

A. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 breaths per minute

B. 20-40 breaths per minute, abdominal breathing with active use of intercostals muscles

C. 30-60 breaths per minute with apnea lasting more than 15 seconds, abdominal breathing

D. 30-50 breaths per minute, active use of abdominal and intercostal muscles

 

24. The anterior fontanelle is characterized as:

 

A. 3-4 cm anteroposterior diameter and 2-3 cm transverse diameter, diamond shape

B. 2-3 cm anteroposterior diameter and 3-4 cm transverse diameter and diamond shape

C. 2-3 cm in both anteroposterior and transverse diameter and diamond shape

D. none of the above

 

25. The ideal site for vitamin K injection in the newborn is:

 

A. Right upper arm

B. Left upper arm

C. Either right or left buttocks

D. Middle third of the thigh

 

26. At what APGAR score at 5 minutes after birth should resuscitation be initiated?

 

A. 1-3

B. 7-8

C. 9-10

D. 6-7

 

27. Right after birth, when the skin of the baby’s trunk is pinkish but the soles of the feet and palm of the hands are bluish this is called:

 

A. Syndactyly

B. Acrocyanosis

C. Peripheral cyanosis

D. Cephalo-caudal cyanosis

 

28. The minimum birth weight for full-term babies to be considered normal is:

 

A. 2,000gms

B. 1,500gms

C. 2,500gms

D. 3,000gms

 

29. This procedure is done to prevent ophthalmia neonatorum is:

 

A. Marmet’s technique

B. Crede’s method

C. Ritgen’s method

D. Ophthalmic wash

 

30. Which of the following characteristics will distinguish a postmature neonate at birth?

 

A. Plenty of lanugo and vernix caseosa

B. Lanugo mainly on the shoulders and vernix in the skin folds

C. Pinkish skin with good turgor

D. Almost leather-like, dry, cracked skin, negligible vernix caseosa

 

31. What would be the appropriate first nursing action when caring for a 20-year old G1P0 woman at 39 weeks gestation who is in active labor and for whom an assessment reveals mild variable fetal heart rate decelerations?

 

A. Notify the physician

B. Prepare the client for immediate delivery

C. Readjust the fetal monitor

D. Change the maternal position

 

32. Birth Control Methods and Infertility:

In basal body temperature (BBT) technique, the sign that ovulation has occurred is an elevation of body temperature by

 

A. 1.0-1.4 degrees centigrade

B. 0.2-0.4 degrees centigrade

C. 2.0-4.0 degrees centigrade

D. 1.0-4.0 degrees centigrade

 

33. Lactation Amenorrhea Method(LAM) can be an effective method of natural birth control if

 

A. The mother breastfeeds mainly at night time when ovulation could possibly occur

B. The mother breastfeeds exclusively and regularly during the first 6 months without giving supplemental feedings

C. The mother uses mixed feeding faithfully

D. The mother breastfeeds regularly until 1 year with no supplemental feedings

 

34. The intra-uterine device prevents pregnancy by the ffg mechanism EXCEPT

 

A. Endometrium inflames

B. Fundus contracts to expel uterine contents

C. Copper embedded in the IUD can kill the sperms

D. Sperms will be barred from entering the fallopian tubes

 

35. Oral contraceptive pills are of different types. Which type is most appropriate for mothers who are breastfeeding?

 

A. Estrogen-only

B. Progesterone only

C. Mixed type- estrogen and progesterone

D. 21-day pills mixed type

 

36. The natural family planning method called Standard Days (SDM), is the latest type and easy to use methoD. However, it is a method applicable only to women with regular menstrual cycles between ___ to ___ days.

 

A. 21-26 days

B. 26-32 days

C. 28-30 days

D. 24- 36 days

 

37. Which of the following are signs of ovulation?

1. Mittelschmerz;

2. Spinnbarkeit;

3. Thin watery cervical mucus;

4. Elevated body temperature of 4.0 degrees centigrade

 

A. 1 & 2

B. 1, 2, & 3

C. 3 & 4

D. 1, 2, 3, 4

 

38. The following methods of artificial birth control works as a barrier device EXCEPT:

 

A. Condom

B. Cervical cap

C. Cervical Diaphragm

D. Intrauterine device (IUD)

 

39. Which of the following is a TRUE statement about normal ovulation?

 

A. It occurs on the 14th day of every cycle

B. It may occur between 14-16 days before next menstruation

C. Every menstrual period is always preceded by ovulation

D. The most fertile period of a woman is 2 days after ovulation

 

40. If a couple would like to enhance their fertility, the following means can be done:

 

1. Monitor the basal body temperature of the woman every day to determine peak period of fertility;

2. Have adequate rest and nutrition;

3. Have sexual contact only during the dry period of the woman;

4. Undergo a complete medical check-up to rule out any debilitating disease

 

A. 1 only

B. 1 & 4

C. 1,2,4

D. 1,2,3,4

 

41. In the sympto-thermal method, the parameters being monitored to determine if the woman is fertile or infertile are:

 

A. Temperature, cervical mucus, cervical consistency

B. Release of ovum, temperature, and vagina

C. Temperature and wetness

D. Temperature, endometrial secretion, mucus

 

42. The following are important considerations to teach the woman who is on a low dose (mini-pill) oral contraceptive EXCEPT:

 

A. The pill must be taken every day at the same time

B. If the woman fails to take a pill in one day, she must take 2 pills for added protection

C. If the woman fails to take a pill in one day, she needs to take another temporary method until she has consumed the whole pack

D. If she is breastfeeding, she should discontinue using mini-pill and use the progestin-only type

 

43. To determine if the cause of infertility is a blockage of the fallopian tubes, the test to be done is

 

A. Huhner’s test

B. Rubin’s test

C. Postcoital test

D. None of the above

 

44. Infertility can be attributed to male causes such as the following EXCEPT:

 

A. Cryptorchidism

B. Orchitis

C. Sperm count of about 20 million per milliliter

D. Premature ejaculation

 

45. Spinnbarkeit is an indicator of ovulation which is characterized as:

 

A. Thin watery mucus which can be stretched into a long strand about 10 cm

B. Thick mucus that is detached from the cervix during ovulation

C. Thin mucus that is yellowish in color with fishy odor

D. Thick mucus vaginal discharge influence by high level of estrogen

 

46. Vasectomy is a procedure done on a male for sterilization. The organ involved in this procedure is

 

A. Prostate gland

B. Seminal vesicle

C. Testes

D. Vas deferens

 

47. Breast self-examination is best done by the woman on herself every month during

 

A. The middle of her cycle to ensure that she is ovulating

B. During the menstrual period

C. Right after the menstrual period so that the breast is not being affected by the increase in hormones particularly estrogen

D. Just before the menstrual period to determine if ovulation has occurred

 

48. A woman is considered to be menopause if she has experienced cessation of her menses for a period of

 

A. 6 months

B. 12 months

C. 18 months

D. 24 months

 

49. Which of the following is the correct practice of self-breast examination in a menopausal woman?

 

A. She should do it at the usual time that she experiences her menstrual period in the past to ensure that her hormones are not at its peak

B. Any day of the month as long it is regularly observed on the same day every month

C. Anytime she feels like doing it ideally every day

D. Menopausal women do not need regular self-breast exam as long as they do it at least once every 6 months

 

50. In assisted reproductive technology (ART), there is a need to stimulate the ovaries to produce more than one mature ovA. The drug commonly used for this purpose is:

 

A. Bromocriptine

B. Clomiphene

C. Provera

D. Estrogen

 

51. A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman’s vital signs:

 

A. Every 30 minutes during the first hour and then every hour for the next two hours.

B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

C. Every hour for the first 2 hours and then every 4 hours

D. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.

 

52. A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother’s temperature is 100.2*F. Which of the following actions would be most appropriate?

 

A. Retake the temperature in 15 minutes

B. Notify the physician

C. Document the findings

D. Increase hydration by encouraging oral fluids

 

53. The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?

 

A. Obtain hemoglobin and hematocrit levels

B. Instruct the mother to request help when getting out of bed

C. Elevate the mother’s legs

D. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided.

 

54. A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?

 

A. Ask the client to turn on her side

B. Ask the client to lie flat on her back with the knees and legs flat and straight.

C. Ask the mother to urinate and empty her bladder

D. Massage the fundus gently before determining the level of the fundus.

 

55. The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is:

 

A. Normal

B. Indicates the presence of infection

C. Indicates the need for increasing oral fluids

D. Indicates the need for increasing ambulation

 

56. When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?

 

A. Document the findings

B. Notify the physician

C. Reassess the client in 2 hours

D. Encourage increased intake of fluids.

 

57. A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:

 

A. One peripad per day

B. Two peripads per day

C. Three peripads per day

D. Eight peripads per day

 

58. A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:

 

A. One the day of the delivery

B. 3 days PP

C. 7 days PP

D. within 2 weeks PP

 

59. Select all of the physiological maternal changes that occur during the PP period.

 

A. Cervical involution occurs

B. Vaginal distention decreases slowly

C. Fundus begins to descend into the pelvis after 24 hours

D. Cardiac output decreases with resultant tachycardia in the first 24 hours

E. Digestive processes slow immediately.

 

60. A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma?

 

A. Complaints of a tearing sensation

B. Complaints of intense pain

C. Changes in vital signs

D. Signs of heavy bruising

 

61. A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client?

 

A. Assess vital signs every 4 hours

B. Inform health care provider of assessment findings

C. Measure fundal height every 4 hours

D. Prepare an ice pack for application to the area.

 

62. A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to:

 

A. Monitor fundal height

B. Apply perineal pressure

C. Prepare the client for surgery.

D. Reassure the client

 

63. A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss?

 

A. A temperature of 100.4*F

B. An increase in the pulse from 88 to 102 BPM

C. An increase in the respiratory rate from 18 to 22 breaths per minute

D. A blood pressure change from 130/88 to 124/80 mm Hg

 

64. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially?

 

A. Massage the fundus until it is firm

B. Elevate the mother’s legs

C. Push on the uterus to assist in expressing clots

D. Encourage the mother to void

 

65. A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present?

 

A. Paleness of the calf area

B. Enlarged, hardened veins

C. Coolness of the calf area

D. Palpable dorsalis pedis pulses

 

66. A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching?

 

1. “I need to take antibiotics, and I should begin to feel better in 24-48 hours.”

2. “I can use analgesics to assist in alleviating some of the discomfort.”

3. “I need to wear a supportive bra to relieve the discomfort.”

4. “I need to stop breastfeeding until this condition resolves.”

 

67. A PP client is being treated for DVT. The nurse understands that the client’s response to treatment will be evaluated by regularly assessing the client for:

 

A. Dysuria, ecchymosis, and vertigo

B. Epistaxis, hematuria, and dysuria

C. Hematuria, ecchymosis, and epistaxis

D. Hematuria, ecchymosis, and vertigo

 

68. A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to:

 

A. Assess for hypovolemia and notify the health care provider

B. Begin hourly pad counts and reassure the client

C. Begin fundal massage and start oxygen by mask

D. Elevate the head of the bed and assess vital signs

 

69. A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following?

 

A. Massage the fundus

B. Place the mother in the Trendelenburg’s position

C. Notify the physician

D. Record the findings

 

70. A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered?

 

A. Prothrombin time

B. International normalized ratio

C. Activated partial thromboplastin time

D. Platelet count

 

71. A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list.

 

A. Take the prescribed antibiotics until the soreness subsides.

B. Wear supportive bra

C. Avoid decompression of the breasts by breastfeeding or breast pump

D. Rest during the acute phase

5. Continue to breastfeed if the breasts are not too sore.

 

72. Methergine or Pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the:

 

A. Amount of lochia

B. Blood pressure

C. Deep tendon reflexes

D. Uterine tone

 

73. Methergine or Pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client’s medical history?

 

A. Peripheral vascular disease

B. Hypothyroidism

C. Hypotension

D. Type 1 diabetes

 

74. Which of the following factors might result in a decreased supply of breastmilk in a PP mother?

 

A. Supplemental feedings with formula

B. Maternal diet high in vitamin C

C. An alcoholic drink

D. Frequent feedings

 

75. Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts?

 

A. Applying ice

B. Applying a breast binder

C. Teaching how to express her breasts in a warm shower

D. Administering bromocriptine (Parlodel)

 

76. On completing a fundal assessment, the nurse notes the fundus is situated on the client’s left abdomen. Which of the following actions is appropriate?

 

A. Ask the client to empty her bladder

B. Straight catheterize the client immediately

C. Call the client’s health provider for direction

D. Straight catheterize the client for half of her uterine volume

 

77. The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum?

 

A. Lower than during her pregnancy

B. Higher than during her pregnancy

C. Lower than before she became pregnant

D. Higher than before she became pregnant

 

78. Which of the following findings would be expected when assessing the postpartum client?

 

A. Fundus 1 cm above the umbilicus 1 hour postpartum

B. Fundus 1 cm above the umbilicus on a postpartum day 3

C. Fundus palpable in the abdomen at 2 weeks postpartum

D. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2

 

79. A client is complaining of painful contractions, or after pains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains?

 

A. Bottle-feeding

B. Diabetes

C. Multiple gestation

D. Primiparity

 

80. On which of the postpartum days can the client expect lochia serosa?

 

A. Days 3 and 4 PP

B. Days 3 to 10 PP

C. Days 10-14 PP

D. Days 14 to 42 PP

 

81. Which of the following behaviors characterizes the PP mother in the taking in phase?

 

A. Passive and dependant

B. Striving for independence and autonomy

C. Curious and interested in care of the baby

D. Exhibiting maximum readiness for new learning

 

82. Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus?

 

A. Retained placental fragments

B. Urinary tract infection

C. Cervical laceration

D. Uterine atony

 

83. What type of milk is present in the breasts 7 to 10 days PP?

 

A. Colostrum

B. Hind milk

C. Mature milk

D. Transitional milk

 

84. Which of the following complications is most likely responsible for a delayed postpartum hemorrhage?

 

A. Cervical laceration

B. Clotting deficiency

C. Perineal laceration

D. Uterine subinvolution

 

85. Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching?

 

A. The vaccine is safe in clients with egg allergies

B. Breastfeeding isn’t compatible with the vaccine

C. Transient arthralgia and rash are common adverse effects

D. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects

 

86. Which of the following changes best described the insulin needs of a client with type 1 diabetes who has just delivered an infant vaginally without complications?

 

A. Increase

B. Decrease

C. Remain the same as before pregnancy

D. Remain the same as during pregnancy

 

87. Which of the following responses is most appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health?

 

A. Mothers with diabetes who breastfeed have a hard time controlling their insulin needs

B. Mothers with diabetes shouldn’t breastfeed because of potential complications

C. Mothers with diabetes shouldn’t breastfeed; insulin requirements are doubled.

D. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.

 

88. On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases?

 

A. Depression phase

B. Letting-go phase

C. Taking-hold phase

D. Taking-in phase

 

89. Which of the following physiological responses is considered normal in the early postpartum period?

 

A. Urinary urgency and dysuria

B. Rapid diuresis

C. Decrease in blood pressure

D. Increase motility of the GI system

 

90. During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make?

 

A. The client appears interested in learning about neonatal care

B. The client talks a lot about her birth experience

C. The client sleeps whenever the neonate isn’t present

D. The client requests help in choosing a name for the neonate.

 

91. Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage?

 

A. Hypertension

B. Cervical and vaginal tears

C. Urine retention

D. Endometritis

 

92. Which type of lochia should the nurse expect to find in a client 2 days PP?

 

A. Foul-smelling

B. Lochia serosa

C. Lochia alba

D. Lochia rubra

 

93. After the expulsion of the placenta in a client who has six living children, an infusion of lactated ringer’s solution with 10 units of Pitocin is ordered. The nurse understands that this is indicated for this client because:

 

A. She had a precipitate birth

B. This was an extramural birth

C. Retained placental fragments must be expelled

D. Multigravidas are at increased risk for uterine atony.

 

94. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum.  An expected finding would be:

 

A. Soft, non-tender; colostrum is present

B. Leakage of milk at let down

C. Swollen, warm, and tender upon palpation

D. A few blisters and a bruise on each areola

 

95. Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born.  The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that:

 

A. Return to pre-pregnant weight is usually achieved by the end of the postpartum period

B. Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-pound weight loss

C. The expected weight loss immediately after birth averages about 11 to 13 pounds

D. Lactation will inhibit weight loss since caloric intake must increase to support milk production

 

96. Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum?

 

A. Postural hypotension

B. Temperature of 100.4°F

C. Bradycardia — pulse rate of 55 BPM

D. Pain in left calf with dorsiflexion of left foot

 

97. The nurse examines a woman one hour after birth.  The woman’s fundus is boggy, midline, and 1 cm below the umbilicus.  Her lochial flow is profuse, with two plum-sized clots.  The nurse’s initial action would be to:

 

A. Place her on a bedpan to empty her bladder

B. Massage her fundus

C. Call the physician

D. Administer Methergine 0.2 mg IM which has been ordered prn

 

98. When performing a postpartum check, the nurse should:

 

A. Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum

B. Assist the woman into a supine position with her arms above her head and her legs extended for the examination of her abdomen

C. Instruct the woman to avoid urinating just before the examination since a full bladder will facilitate fundal palpation

D. Wash hands and put on sterile gloves before beginning the check

 

99. Perineal care is an important infection control measure.  When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:

 

A. Uses soap and warm water to wash the vulva and perineum

B. Washes from symphysis pubis back to episiotomy

C. Changes her perineal pad every 2 – 3 hours

D. Uses the peri bottle to rinse upward into her vagina

 

100. Which measure would be least effective in preventing postpartum hemorrhage?

 

A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered

B. Encourage the woman to void every 2 hours

C. Massage the fundus every hour for the first 24 hours following birth

D. Teach the woman the importance of rest and nutrition to enhance healing

 

101. When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically:

 

A. Express a strong need to review events and her behavior during the process of labor and birth

B. Exhibit a reduced attention span, limiting readiness to learn

C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn

D. Have reestablished her role as a spouse/partner

 

102. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep.  The nurse should:

 

A. Tell the woman she can rest after she feeds her baby

B. Recognize this as a behavior of the taking-hold stage

C. Record the behavior as ineffective maternal-newborn attachment

D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

 

103. Parents can facilitate the adjustment of their other children to a new baby by:

 

A. Having the children choose or make a gift to give to the new baby upon its arrival home

B. Emphasizing activities that keep the new baby and other children together

C. Having the mother carry the new baby into the home so she can show the other children the new baby

D. Reducing stress on other children by limiting their involvement in the care of the new baby

 

104. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth.  The nurse, recognizing the needs of women during this stage, should:

 

A. Foster an active role in the baby’s care

B. Provide time for the mother to reflect on the events of and her behavior during childbirth

C. Recognize the woman’s limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now

D. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs

 

105. All of the following are important in the immediate care of the premature neonate.  Which nursing activity should have the greatest priority?

 

A. Instillation of antibiotic in the eyes

B. Identification by bracelet and footprints

C. Placement in a warm environment

D. Neurological assessment to determine gestational age

 

Answers and Rationale

 

1. Answer: A. 1.0 cm

The uterus will begin involution right after delivery. It is expected to regress/go down by 1 cm. per day and becomes no longer palpable about 1 week after delivery.

 

2. Answer: C. Reddish with some mucus

Right after delivery, the vaginal discharge called lochia will be reddish because there is some blood, endometrial tissue, and mucus. Since it is not pure blood it is non-clotting.

 

3. Answer: B. 7-10 days

Normally, lochia disappears after 10 days postpartum. What’s important to remember is that the color of lochia gets to be lighter (from reddish to whitish) and scantier every day.

 

4. Answer: B. Prevent the mother from producing antibodies against the Rh(+) antigen that she may have gotten when she delivered to her Rh(+) baby

In Rh incompatibility, a Rh(-) mother will produce antibodies against the fetal Rh (+) antigen which she may have gotten because of the mixing of maternal and fetal blood during labor and delivery. Giving her RhoGam right after birth will prevent her immune system from being permanently sensitized to Rh antigen.

 

5. Answer: C. Exercise adequately like aerobics

All the above nursing measures are needed to ensure that the mother is in a healthy state. However, aerobics does not necessarily enhance lactation.

 

6. Answer: B. Apply warm compress on the engorged breast

Warm compress is applied if the purpose is to relieve pain but ensure lactation to continue. If the purpose is to relieve pain as well as suppress lactation, the compress applied is cold.

 

7. Answer: C. 6-8 hrs

A woman who has had normal delivery is expected to void within 6-8 hrs. If she is unable to do so after 8 hours, the nurse should stimulate the woman to void. If nursing interventions to stimulate spontaneous voiding don’t work, the nurse may decide to catheterize the woman.

 

8. Answer: A. Breastfeed the baby on self-demand day and night

Feeding on self-demand means the mother feeds the baby according to baby’s need. Therefore, this means there will be regular emptying of the breasts, which is essential to maintain adequate lactation.

 

9. Answer: D. Elevate the affected leg and keep the patient on bedrest

If the mother already has thrombophlebitis, the nursing intervention is bedrest to prevent the possible dislodging of the thrombus and keeping the affected leg elevated to help reduce the inflammation.

 

10. Answer: A. Excessive analgesia was given to the mother

Excessive analgesia can lead to uterine relaxation thus lead to hemorrhage postpartally. Both B and D are normal and C is at the vaginal introitus thus will not affect the uterus.

 

11. Answer: B. Taking-in, taking-hold and letting-go

Rubin’s theory states that the 3 stages that a mother goes through for maternal adaptation are: taking-in, taking-hold and letting-go. In the taking-in stage, the mother is more passive and dependent on others for care. In taking-hold, the mother begins to assume a more active role in the care of the child and in letting-go, the mother has become adapted to her maternal role.

 

12. Answer: B. There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin

If the mother is diabetic, the fetus while in utero has a high supply of glucose. When the baby is born and is now separate from the mother, it no longer receives a high dose of glucose from the mother. In the first few hours after delivery, the neonate usually does not feed yet thus this can lead to hypoglycemia.

 

13. Answer: B. BP diastolic increase from 80 to 95mm Hg

All the vital signs given in the choices are within normal range except an increase of 15mm Hg in the diastolic which is a possible sign of hypertension in pregnancy.

 

14. Answer: B. Level of umbilicus

Immediately after the delivery of the placenta, the fundus of the uterus is expected to be at the level of the umbilicus because the contents of the pregnancy have already been expelled. The fundus is expected to recede by 1 fingerbreadths (1cm) every day until it becomes no longer palpable above the symphysis pubis.

 

15. Answer: B. Heavy

Heavy lochial discharge is a saturated menstrual pad in 1 hour.

 

Option A: Excessive = menstrual pad saturated in 15 minutes.

Option C: Light = less than 10 cm on a menstrual pad in 1 hour.

Option D: Scanty = less than 2.5 cm on a menstrual pad in 1 hour.

 

16. Answer: B. 6-8 weeks

When the mother does not breastfeed, the normal menstruation resumes about 6-8 weeks after delivery. This is due to the fact that after delivery, the hormones estrogen and progesterone gradually decrease thus triggering negative feedback to the anterior pituitary to release the Follicle-Stimulating Hormone (FSH) which in turn stimulates the ovary to again mature a Graafian follicle and the menstrual cycle post pregnancy resumes.

 

17. Answer: D. Application of cold compress on the breast

To stimulate lactation, a warm compress is applied to the breast. A cold application will cause vasoconstriction thus reducing the blood supply consequently the production of milk.

 

18. Answer: A. Laceration of soft tissues of the cervix and vagina

When the uterus is firm and contracted it means that the bleeding is not in the uterus but other parts of the passageway such as the cervix or the vagina.

 

19. Answer: C. Massage the fundus vigorously for 15 minutes until contracted

Massaging the fundus of the uterus should not be vigorous and should only be done until the uterus feels firm and contracted. If the massage is vigorous and prolonged, the uterus will relax due to over stimulation.

 

20. Answer: D. Perineal care

Perineal care is primarily done for personal hygiene regardless of whether there is pain or not; episiotomy wound or not.

 

21. Answer: A. All of the above

All the symptoms 1-3 are characteristic of postpartal blues. It will resolve by itself because it is transient and is due to a number of reasons like changes in hormonal levels and adjustment to motherhood. If symptoms last more than 2 weeks, this could be a sign of abnormality like postpartum depression and needs treatment.

 

22. Answer: A. The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is mixed blood.

The fetal lungs are fluid-filled while in utero and are still not functioning. It only begins to function in extrauterine life. Except for the blood as it enters the fetus immediately from the placenta, most of the fetal blood is mixed blood.

 

23. Answer: A. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 breaths per minute

A newly born baby still is adjusting to extra uterine life and the lungs are just beginning to function as a respiratory organ. The respiration of the baby at this time is characterized as usually shallow and irregular with short periods of apnea, 30-60 breaths per minute. The apneic periods should be brief lasting, not more than 15 seconds otherwise it will be considered abnormal.

 

24. Answer: A. 3-4 cm anteroposterior diameter and 2-3 cm transverse diameter, diamond shape

The anterior fontanelle is a diamond shape with the anteroposterior diameter being longer than the transverse diameter. The posterior fontanelle is a triangular shape.

 

25.Answer: D. Middle third of the thigh

Neonates do not have well-developed muscles of the arm. Since Vitamin K is given intramuscular, the site must have sufficient muscles like the middle third of the thigh.

 

26.Answer: A. 1-3

An APGAR of 1-3 is a sign of fetal distress which requires resuscitation. The baby is alright if the score is 8-10.

 

27. Answer: B. Acrocyanosis

Acrocyanosis is the term used to describe the baby’s skin color at birth when the soles and palms are bluish but the trunk is pinkish.

 

28. Answer: C. 2,500gms

According to the WHO standard, the minimum normal birth weight of a full-term baby is 2,500 gms or 2.5 Kg.

 

29. Answer: B. Crede’s method

Crede’s method/prophylaxis is the procedure done to prevent ophthalmia neonatorum which the baby can acquire as it passes through the birth canal of the mother. Usually, an ophthalmic ointment is used.

 

30. Answer: D. Almost leather-like, dry, cracked skin, negligible vernix caseosa

A post mature fetus has the appearance of an old person with dry wrinkled skin and the vernix caseosa has already diminished.

 

31. Answer: D. Change the maternal position

The cause of variable fetal heart decelerations is umbilical cord compression, which can usually be corrected by changing the maternal position.

 

32. Answer: B. 0.2-0.4 degrees centigrade

The release of the hormone progesterone in the body following ovulation causes a slight elevation of basal body temperature of about 0.2 – 0.4 degrees centigrade

 

33. Answer: B. The mother breastfeeds exclusively and regularly during the first 6 months without giving supplemental feedings

A mother who breastfeeds exclusively and regularly during the first 6 months benefits from lactation amenorrhea. There is evidence to support the observation that the benefits of lactation amenorrhea last for 6 months provided the woman has not had her first menstruation since delivery of the baby.

 

34. Answer: D. Sperms will be barred from entering the fallopian tubes

An intrauterine device is a foreign body so that if it is inserted into the uterine cavity, the initial reaction is to produce inflammatory process and the uterus will contract in order to try to expel the foreign body. Usually, IUDs are coated with copper to serve as spermicide killing the sperms deposited into the female reproductive tract. But the IUD does not completely fill up the uterine cavity thus sperms which are microscopic is size can still pass through.

 

35. Answer: B. Progesterone only

If the mother is breastfeeding, the progesterone only type is the best because estrogen can affect lactation.

 

36. Answer: B. 26-32 days

Standard Days Method (SDM) requires that the menstrual cycles are regular between 26-32 days. There is no need to monitor temperature or mucus secretion. This natural method of family planning is very simple since all that the woman pays attention to is her cycle. With the aid of CycleBeads, the woman can easily monitor her cycles.

 

37. Answer: B. 1, 2, & 3

Mittelschmerz, spinnbarkeit and thin watery cervical mucus are signs of ovulation. When ovulation occurs, the hormone progesterone is released which can cause a slight elevation of temperature between 0.2-0.4 degrees centigrade and not 4 degrees centigrade.

 

38. Answer: D. Intrauterine device (IUD)

Intrauterine device prevents pregnancy by not allowing the fertilized ovum from implanting on the endometrium. Some IUDs have copper added to it which is spermicidal. It is not a barrier since the sperms can readily pass through and fertilize an ovum at the fallopian tube.

 

39. Answer: B. It may occur between 14-16 days before next menstruation

Not all menstrual cycles are ovulatory. Normal ovulation in a woman occurs between the 14th to the 16th day before the NEXT menstruation. A common misconception is that ovulation occurs on the 14th day of the cycle. This is a misconception because ovulation is determined NOT from the first day of the cycle but rather 14-16 days BEFORE the next menstruation.

 

40. Answer: C. 1,2,4

All of the above are essential for enhanced fertility except no. 3 because during the dry period the woman is in her infertile period thus even when sexual contact is done, there will be no ovulation, thus fertilization is not possible.

 

41.Answer: A. Temperature, cervical mucus, cervical consistency

The 3 parameters measured/monitored which will indicate that the woman has ovulated are- a temperature increase of about 0.2-0.4 degrees centigrade, a softness of the cervix and cervical mucus that looks like the white of an egg which makes the woman feel “wet”.

 

42. Answer: B. If the woman fails to take a pill in one day, she must take 2 pills for added protection

If the woman fails to take her usual pill for the day, taking a double dose does not give additional protection. What she needs to do is to continue taking the pills until the pack is consumed and use at the time another temporary method to ensure that no pregnancy will occur. When a new pack is started, she can already discontinue using the second temporary method she employed.

 

43.Answer: B. Rubin’s test

Rubin’s test is a test to determine patency of fallopian tubes. Huhner’s test is also known as post-coital test to determine the compatibility of the cervical mucus with sperms of the sexual partner.

 

44. Answer: C. Sperm count of about 20 million per milliliter

Sperm count must be within normal in order for a male to successfully sire a child. The normal sperm count is 20 million per milliliter of seminal fluid or 50 million per ejaculate.

 

45. Answer: A. Thin watery mucus which can be stretched into a long strand about 10 cm

At the midpoint of the cycle when the estrogen level is high, the cervical mucus becomes thin and watery to allow the sperm to easily penetrate and get to the fallopian tubes to fertilize an ovum. This is called spinnbarkeit. And the woman feels “wet”. When progesterone is secreted by the ovary, the mucus becomes thick and the woman will feel “dry”.

 

46. Answer: D. Vas deferens

Vasectomy is a procedure wherein the vas deferens of the male is ligated and cut to prevent the passage of the sperms from the testes to the penis during ejaculation.

 

47. Answer: C. Right after the menstrual period so that the breast is not being affected by the increase in hormones particularly estrogen

 

The best time to do self-breast examination is right after the menstrual period is over so that the hormonal level is low thus the breasts are not tender.

 

48. Answer: B. 12 months

 

If a woman has not had her menstrual period for 12 consecutive months, she is considered to be in her menopausal stage.

 

49. Answer: B. Any day of the month as long it is regularly observed on the same day every month

Menopausal women still need to do self-examination of the breast regularly. Any day of the month is alright provided that she practices it monthly on the same day that she has chosen. The hormones estrogen and progesterone are already diminished during menopause so there is no need to consider the time to do it in relation to the menstrual cycle.

 

50. Answer: B. Clomiphene

 

Clomiphene or Clomid acts as an ovarian stimulant to promote ovulation. The mature ova are retrieved and fertilized outside the fallopian tube (in-vitro fertilization) and after 48 hours the fertilized ovum is inserted into the uterus for implantation.

  

    

51. Answer: 2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

 

52. Answer: D. Increase hydration by encouraging oral fluids.

 

The mother’s temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading.

 

Option C: Although the nurse would document the findings, the most appropriate action would be to increase the hydration.

 

53. Answer: B. Instruct the mother to request help when getting out of bed.

 

Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client’s safety. The nurse should advise the mother to get help the first few times the mother gets out of bed.

 

Option A: Obtaining an H/H requires a physician’s order.

 

54. Answer: C. Ask the mother to urinate and empty her bladder.

 

Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done.

 

Options A and B: When the nurse is performing a fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed.

Option D: Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.

 

55. Answer: B. Indicates the presence of infection.

 

Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal.

 

Option A: Normal lochia has a fleshy odor.

Options C and D: Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention.

 

56. Answer: B. Notify the physician.

 

Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.

 

57. Answer: D. Eight peripads per day.

 

The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.

 

58. Answer: B. 3 days PP.

 

After birth, the nurse should auscultate the woman’s abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function.

 

59. Answer: A and C. In the PP period, cervical healing occurs rapidly and cervical involution occurs.

 

After 1 week the muscle begins to regenerate and the cervix feels firm and the external os, is the width of a pencil.  The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution.

 

Option B: Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state.

Option D: Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period.

Option E: Soon after childbirth, digestion begins to begin to be active, and the new mother is usually hungry because of the energy expended during labor.

 

60. Answer: C. Changes in vital signs.

 

Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma.

Options A and B: Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation.

Option D: Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

 

61. Answer: D. Prepare an ice pack for application to the area.

 

Application of ice will reduce swelling caused by hematoma formation in the vulvar area.

Options A, B, and C: The other options are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

 

62. Answer: C. Prepare the client for surgery.

 

The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.

 

63. Answer: B. An increase in the pulse from 88 to 102 BPM.

 

During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume.

 

Option A: A slight rise in temperature is normal. The respiratory rate is increased slightly.

Option D: The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage.

 

64. Answer: A. Massage the fundus until it is firm.

 

If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus.

 

Options B and D: Elevating the client’s legs and encouraging the client to void will not assist in managing uterine atony.  If the uterus does not remain contracted as a result of the uterine massage, the problem may be distended bladder and the nurse should assist the mother to urinate, but this would not be the initial action.

Option C: Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

65. Answer: B. Enlarged, hardened veins.

 

Thrombosis of the superficial veins is usually accompanied by signs and symptoms of inflammation. These include swelling of the involved extremity and redness, tenderness, and warmth.

 

66. Answer: D. “I need to stop breastfeeding until this condition resolves.”

 

In most cases, the mother can continue to breastfeed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation.

 

Option A:  Antibiotic therapy assists in resolving the mastitis within 24-48 hours

Options B and C: Additional supportive measures include ice packs, breast supports, and analgesics.

 

67. Answer: C. Hematuria, ecchymosis, and epistaxis.

 

The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.

 

68. Answer: A. Assess for hypovolemia and notify the health care provider.

 

Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.

 

69. Answer: C. Notify the physician.

 

If the bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm will not assist in controlling the bleeding. Trendelenburg’s position is to be avoided because it may interfere with cardiac function.

 

70. C. Activated partial thromboplastin time.

 

Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. Activated partial thromboplastin time should be monitored, and a heparin dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control.

 

Options A and B: The prothrombin time and the INR are used to monitor coagulation time when warfarin (Coumadin) is used.

 

71. Answers: B, D, and E.

 

Mastitis are an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3 L a day, and taking analgesics to relieve discomfort. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra.

 

Option A: Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides.

Option C: Continued decompression of the breast by breastfeeding or pumping is important to empty the breast and prevent formation of an abscess.

 

72. Answer: B. Blood pressure.

 

Methergine and pitocin are agents that are used to prevent or control postpartum hemorrhage by contracting the uterus. They cause continuous uterine contractions and may elevate blood pressure. A priority nursing intervention is to check blood pressure. The physician should be notified if hypertension is present.

 

73. Answer: A. Peripheral vascular disease.

 

These medications are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of these medications.

 

74. Answer: A. Supplemental feedings with formula.

 

Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the mother’s nipples affects hormonal levels and milk production.

 

75. Answer: C. Teaching how to express her breasts in a warm shower.

 

Teaching the client how to express her breasts in a warm shower aids with let-down and will give temporary relief. Ice can promote comfort by vasoconstriction, numbing, and discouraging further letdown of milk.

 

76. Answer: A. Ask the client to empty her bladder.

 

A full bladder may displace the uterine fundus to the left or right side of the abdomen. Catheterization is unnecessary invasive if the woman can void on her own.

 

77. Answer: C. Lower than before she became pregnant.

 

PP insulin requirements are usually significantly lower than pre pregnancy requirements. Occasionally, clients may require little to no insulin during the first 24 to 48 hours postpartum.

 

78. Answer: A. Fundus 1 cm above the umbilicus 1 hour postpartum.

 

Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by PP day 3. The fundus shouldn’t be palpated in the abdomen after day 10.

 

79. Answer: C. Multiple gestation.

 

Multiple gestation, breastfeeding, multiparity, and conditions that cause overdistention of the uterus will increase the intensity of after-pains.

 

Options A and B: Bottle-feeding and diabetes aren’t directly associated with increasing severity of afterpains unless the client has delivered a macrosomic infant.

 

80. Answer: B. Days 3 to 10 PP.

 

On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP.

 

81. Answer: A. Passive and dependant.

 

During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate’s needs.

 

Options B, C, and D: The taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for independence and autonomy; she also becomes curious and interested in the care of the baby and is most ready to learn.

 

82. Answer: C. Cervical laceration.

 

Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting.

 

Options A and D: Retained placental fragments and uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than expected.

Option B: UTI won’t cause vaginal bleeding, although hematuria may be present.

 

83. Answer: D. Transitional milk.

 

Transitional milk comes after colostrum and usually lasts until 2 weeks PP.

 

84. Answer: D. Uterine subinvolution.

 

Late postpartum bleeding is often the result of subinvolution of the uterus. Retained products of conception or infection often cause subinvolution.

 

Options A and C: Cervical or perineal lacerations can cause an immediate postpartum hemorrhage.

Option B: A client with a clotting deficiency may also have an immediate PP hemorrhage if the deficiency isn’t corrected at the time of delivery.

 

85. Answer: D. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects.

 

The client must understand that she must not become pregnant for 3 months after the vaccination because of its potential teratogenic effects.

Option A: The rubella vaccine is made from duck eggs so an allergic reaction may occur in clients with egg allergies.

Option B: The virus is not transmitted into the breast milk, so clients may continue to breastfeed after the vaccination.

Option C: Transient arthralgia and rash are common adverse effects of the vaccine.

 

86. Answer: B. Decrease.

 

The placenta produces the hormone human placental lactogen, an insulin antagonist. After birth, the placenta, the major source of insulin resistance, is gone. Insulin needs decrease and women with type 1 diabetes may only need one-half to two-thirds of the prenatal insulin during the first few PP days.

 

87. Answer: D. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.

 

Breastfeeding has an antidiabetogenic effect. Insulin needs are decreased because carbohydrates are used in milk production. Breastfeeding mothers are at a higher risk of hypoglycemia in the first PP days after birth because the glucose levels are lower. Mothers with diabetes should be encouraged to breastfeed.

 

88. Answer: D. Taking-in phase.

 

The taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own needs and requires support from staff and relatives.

Option B: The letting-go phase begins several weeks later when the mother incorporates the new infant into the family unit.

Option C:  The taking-hold phase occurs when the mother is ready to take responsibility for her care as well as the infant’s care.

 

89. Answer: B. Rapid diuresis.

 

In the early PP period, there’s an increase in the glomerular filtration rate and a drop in the progesterone levels, which result in rapid diuresis.

 

Options A: There should be no urinary urgency, though a woman may feel anxious about voiding.

Options C and D: There’s a minimal change in blood pressure following childbirth, and a residual decrease in GI motility.

 

90. Answer: A. The client appears interested in learning about neonatal care.

 

The third to tenth days of PP care are the “taking-hold” phase, in which the new mother strives for independence and is eager for her neonate. The other options describe the phase in which the mother relives her birth experience.

 

91. Answer: C. Urine retention.

 

Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents the uterus from contracting. The uterus needs to remain contracted if bleeding is to stay within normal limits. Cervical and vaginal tears can cause PP hemorrhage but are less common occurrences in the PP period.

 

92. Answer: D. Lochia rubra

 

93. Answer: D. Multigravidas are at increased risk for uterine atony.

 

Multiple full-term pregnancies and deliveries result in overstretched uterine muscles that do not contract efficiently and bleeding may ensue.

 

94. Answer: A. Soft, non-tender; colostrum is present. Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present and may leak from the nipples.

 

95. Answer: C. The expected weight loss immediately after birth averages about 11 to 13 pounds.

 

Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 pounds. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process.

 

96. Answer: D. Pain in left calf with dorsiflexion of left foot.

 

Pain in left calf with dorsiflexion of left foot indicate a positive Homan sign and are suggestive of thrombophlebitis and should be investigated further.

 

Options A and C are expected related to circulatory changes after birth.

Option B: A temperature of 100.4°F in the first 24 hours is most likely indicative of dehydration which is easily corrected by increasing oral fluid intake.

 

97. Answer: B. Massage her fundus.

 

A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm, followed by options C and D, especially if the fundus does not become or remain firm with massage.

 

Option A: There is no indication of a distended bladder since the fundus is midline and below the umbilicus.

 

98. Answer: A. Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum.

 

While the supine position is best for examining the abdomen, the woman should keep her arms at her sides and slightly flex her knees in order to relax abdominal muscles and facilitate palpation of the fundus.

 

Option C: The bladder should be emptied before the check. A full bladder alters the position of the fundus and makes the findings inaccurate.

Option D: Although hands are washed before starting the check, clean (not sterile) gloves are put on just before the perineum and pad are assessed to protect from contact with blood and secretions.

 

99. Answer: D. Uses the peribottle to rinse upward into her vagina.

 

The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

 

100. Answer: C. Massage the fundus every hour for the first 24 hours following birth.

 

The fundus should be massaged only when boggy or soft.  Massaging a firm fundus could cause it to relax.

 

Options A, B, and D are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.

 

101. Answer: C. Express a strong need to review events and her behavior during the process of labor and birth.

 

One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response C. This stage lasts for as long as 4 to 5 weeks after birth.

 

Options A and B are characteristic of the taking-in stage, which lasts for the first few days after birth.

Option D reflects the letting-go stage, which indicates that psychosocial recovery is complete.

 

102. Answer: D. Recognize this as a behavior of the taking-hold stage.

 

The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.

 

Option A does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage.

103. Answer: A. Having the children choose or make a gift to give to the new baby upon its arrival home.

 

Option B: Special time should be set aside just for the other children without interruption from the newborn.

Option C: Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children.

Option D: Children should be actively involved in the care of the baby according to their ability without overwhelming them.

 

104. Answer: B. Provide time for the mother to reflect on the events of and her behavior during childbirth.

 

The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only in her own care but also the care of her newborn.  Women express a need to review their childbirth experience and evaluate their performance.  Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach.

 

105. Answer: C. Placement in a warm environment

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