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1. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following actions should the nurse perform? a. Supervise all infant care. b. Maintain client on strict bed rest. c. Restrict visitation to her partner. d. Carefully monitor toileting ANS: A a. It is essential th...

A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list? A. Wear a supportive bra B. Rest during the acute phase C. Maintain a fluid intake of at least 3000 ml D Continue to b...

D (Rationale: A woman that develops postpartum psychosis usually does so within four weeks of delivery. Only 1% of women develop this disorder. Suicide and infanticide are common and the disorder is considered a medical emergency. Delusions and hallucinations accompany the disorder and the woman ...

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is a) Taking-in, taking-hold, letting-go b) Taking, holding-on, letting-go c) Taking-in, holding-on, letting-go d) Taking-in, taking-on, letting-go Taking-in, takin...

The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is most important for the nurse to take at this time? Check the uterine fundus and lochia. The postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse...

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

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and re...

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most appropriate action is to: a. Leave the infant in the room with the mother. b. Take the infant immediately to ...

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breast...

Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess? A) Respiratory rate 45, irregular B) Costal breathing pattern C) Nasal flaring, rate 65 D) Crackles on auscultation A Typically, respirations in a 2...

Based on the hormonal theory of labor, the nurse anticipates a rise in which of the following to begin a chain of hormonal events that cause labor? A. Cortisol B. Oxytocin C. Progesterone D. Estrogen A. Cortisol The nurse would recognize that the client has experienced lightening when th...

What is the Kleihauer-Betke ("KB") test and when is it used? 1. Used to measure the amount of fetal hemoglobin transferred from a fetus to a mother's bloodstream. 2. Used to detect transplacental hemorrhage (TPH) A client has an extremely high quantitative HCG level. What could the reaso...

2. Uterine tenderness The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. Soft abdomen 2. Ut...

To establish a good interview relationship with an adolescent, which strategy is most appropriate? 1. Asking personal questions unrelated to the situation 2. Writing down everything the teen says 3. Asking open-ended questions 4. Discussing the nurse's own thoughts and feelings about the situ...