POSTPARTUM PERIOD
246. A nurse is taking the vital signs of a client who
gave birth to a healthy newborn 4 hours ago. The
nurse notes that the client's temperature is 37.9°C.
(100.2°F). What is the priority nursing action?
a. Document the findings.
b. Notify the obstetrician.
c. Retake the temperature in 15 minutes.
d. Increase hydration by encouraging oral fluids.
251. A nurse is teaching a postpartum client about
breastfeeding. Which statement should the nurse
include?
a. The diet should include adequate fluid intake.
b. Prenatal vitamins should be discontinued.
c. Soap should be used after each feed to cleanse
the breasts.
d. Birth control measures are unnecessary while
breastfeeding.
247. A nurse is assessing a client who is 6 hours
postpartum after giving birth to a full-term healthy
newborn. The client complains to the nurse of
feelings of faintness and dizziness. Which nursing
action is most appropriate?
a. Raise the head of the client's bed.
b. Obtain hemoglobin and hematocrit levels.
c. Instruct the client to request help when getting out
of bed.
d. Inform the nursery room nurse to avoid bringing
the newborn to the client until the client's
symptoms have subsided.
252. A nurse is preparing to assess the uterine fundus
of a client in the immediate postpartum period. On
palpation, the nurse notes that the uterus feels soft
and boggy. Which intervention is a priority?
a. Elevate the client's legs.
b. Massage the fundus until it is firm.
c. Ask the client to turn to left lateral.
d. Push on the uterus to assist in expressing clots.
248. A nurse is providing education to a client who
had a spontaneous vaginal birth of a healthy
newborn. Which time frame should the nurse relay to
the client regarding the return of bowel function?
a. 3 days postpartum
b. 7 days postpartum
c. On the day of birth
d. Within 2 weeks postpartum
249. A nurse is planning care for a postpartum client
who had a vaginal birth 2 hours ago. The client
required an episiotomy and has several hemorrhoids.
What is the priority nursing consideration for this
client?
a. Client pain level.
b. Inadequate urinary output
c. Client perception of body changes
d. Potential for imbalanced body fluid volume
250. A nurse is providing education to a client who
plans to breastfeed. Which of the following
statements
by
the
client
demonstrates
understanding? Select all that apply.
a. "I should wear a bra that provides support."
b. "Drinking alcohol can affect my milk supply."
c. I will express colostrum/milk onto my nipples after
every feed to help prevent cracking.
d. "I will start my estrogen birth control pills again as
soon as I get home."
e. "I know if my breasts get engorged, I will limit
breastfeeding and supplement the baby."
f. "I will keep a glass of water nearby so I can get
additional fluids easily."
253. A nurse is caring for four postpartum day-one
clients. Which client requires an intervention?
a. The client with mild afterpains
b. The client with a pulse rate of 60 beats/minute
c. The client with colostrum discharge from both
breasts
d. The client with foul-smelling lochia
254. When performing a postpartum 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 nursing action is
most appropriate?
a. Document the findings.
b. Notify the obstetrician.
c. Reassess the client in 2 hours.
d. Encourage increased oral intake of fluids.
255. A nurse is monitoring the amount of lochia of a
client who is 2 hours postpartum and notes that the
client has saturated a perineal pad in 15 minutes. How
should the nurse respond to this finding initially?
a.
b.
c.
d.
Document the finding
Encourage the client to ambulate.
Encourage the client to increase fluid intake.
Inform the obstetrician (OB).
256. The nurse has provided discharge instructions
to a client who delivered a healthy newborn by
Caesarean birth, Which statement made by the client
indicates a need for further instruction?
a. "I will begin abdominal exercises immediately."
b. "I will notify my obstetrician if I develop a fever."
c. "I will turn on my side and push up with my arms
to get out of bed."
d. "I will lift nothing heavier than my newborn baby
for at least 2 weeks."
257. After a precipitous delivery, the nurse notes that
the client is passive and touches her newborn infant
only briefly with her fingertips. What should the nurse
do to help this client process the delivery?
a. Encourage the client to breastfeed soon after
birth.
b. Support the client in her reaction to the newborn
infant.
c. Tell the client that it is important to hold the
newborn.
d. Document a complete account of the client's
reaction on the birth record.
POSTPARTUM COMPLICATIONS
258. The nurse is monitoring a client in the immediate
postpartum period for signs of hemorrhage Which
sign, if noted, would be an early sign of excessive
blood loss?
a. A temperature of 100.4" (38"C)
b. An increase in the pulse rate from 88 to 102 beats
per minute
c. A blood pressure change from 130/88 to 124/80
mm Hg
d. An increase in the respiratory rate from 18 to 22
breaths per minute
259. The nurse is preparing a list of self-care
instructions for a postpartum client who was
diagnosed with mastitis. Which instructions should
be included on the list? Select all that apply.
a. Wear a supportive bra.
b. Rest during the acute phase.
c. Maintain a fluid intake of at least 3000 ml/day.
d. Continue to breast-feed if the breasts are not too
sore.
e. Take the prescribed antibiotics until the sore ness
subsides
f. Avoid decompression of the breasts by breast
feeding or breast pump.
260. The nurse is providing instructions about
measures to prevent postpartum mastitis to a client
who is breast feeding her newborn. Which client
statement would indicate a need for further
instruction?
a. "I should breast-feed every 2 to 3 hours."
b. "I should change the breast pads frequently."
c. "I should wash my hands well before
breastfeeding"
d. "I should wash my nipples daily with soap and
water."
261. The postpartum nurse is assessing a client who
delivered a healthy infant by cesarean section for
signs and symptoms of superficial venous
thrombosis. Which sign should the nurse note if
superficial venous thrombosis were present?
a. Paleness of the calf area
b. Coolness of the calf area
c. Enlarged, hardened veins
d. Palpable dorsalis pedis pulses
262. A client in a postpartum unit complains of
sudden sharp chest pain and dyspnea: The nurse
notes that the client is tachycardic and the respiratory
rate is elevated. The nurse suspects a pulmonary
embolism. Which should be the initial nursing action?
a. Initiate an intravenous line
b. Assess the client's blood pressure.
c. Prepare to administer morphine sulfate
d. Administer oxygen, 8 to 10 1/minute by face
mask.
263. The nurse is assessing a client in the fourth
stage of labor and notes that the fundus is firm, but
that bleeding is excessive. Which should be the initial
nursing action?
a. Record the findings.
b. Massage the fundus.
c. Notify the obstetrician (OB).
d. 4Place the client in Trendelenburg's position.
264. The nurse is preparing to care for four assigned
clients. Which client is at most risk for hemorrhage?
a. A primiparous client who delivered 4 hours ago
b. A multiparous client who delivered 6 hours ago
c. A multiparous client who delivered a large baby
after oxytocin induction
d. A primiparous client who delivered 6 hours ago
and had epidural anesthesia
265. A postpartum client is diagnosed with cystitis.
The nurse should plan for which priority action in the
care of the client?
a. Providing sitz baths
b. Encouraging fluid intake
c. Placing ice on the perineum
d. Monitoring hemoglobin and hematocrit levels
266. The nurse is monitoring a postpartum client who
received epidural anesthesia for delivery for the
presence of a vulvar hematoma: Which assessment
finding would best indicate the presence of at
hematoma?
a. Changes in vital signs
b. Signs of heavy bruising
c. Complaints of intense pain.
d. Complaints of a tearing sensation
267. The nurse is creating a plan of care for a
postpartum client with a small vulvar hematoma. The
nurse should. include which specific action during
the first 12 hours after delivery?
a. Encourage ambulation hourly
b. Assess vital signs every 4 hours.
c. Measure fundal height every 4 hours
d. Prepare an ice pack for application to the area.
268. On assessment of a postpartum client, the nurse
notes that the uterus feels soft and boggy. The nurse
should take which initial action?
a. Document the findings.
b. Elevate the client's legs.
c. Massage the fundus until it is firm
d. Push on the uterus to assist in expressing clots.