NUR 230 Exam 2 questions
A breastfeeding client is day 4 post Cesarean delivery. Current VS are temp. 99.8, RR 20, HR 88, and BP
118/60. What is the priority in this scenario?
A. Massage the fundus
B. Notify the physician
C. Reassess thr client's temp in 30 minutes
D. Assess the client's breasts for engorgement. - Answer-D
During a postpartum assessment, a cluster of hemorrhoids are noted in a G1P1 who delivered vaginally
with a superficial perineal laceration. Which of the following would be appropriate for the nurse to
include in the women's health teaching? SATA
A. The client should use a site bath three times a day for relief.
B. The client should apply a topical anesthetic as a relief measure.
C. The client should massage the hemorrhoids daily.
D. The client should be advised that the hemorrhoids will increase in size and number with each
subsequent pregnancy.
E. The client can use the side lying position to relieve pressure on the hemorrhoids.
F. The client should use witch hazel pads to soothe the area. - Answer-A, B, E, F
Which is the best intervention to help prevent development of postpartum thrombophlebitis after an
uncomplicated vaginal delivery?
A. Promote adequate oral fluid intake
B. Promote early and frequent ambulation
C. Place sequential compression devices on all patients
,D. Administer subcutaneous low molecular weight heparin - Answer-B
A G6 P4114 is 1/2 hour post spontaneous vaginal delivery of a 440 grams baby. Initially, which
complication should the nurse monitor considering this patient scenario?
A. Maternal hypoglycemia
B. Maternal hyperglycemia
C. Maternal VTE
D. Maternal uterine atony - Answer-D
The nurse is teaching a postpartum mother about changes in the postpartum period. The nurse
recognized the mother needs additional teaching when the mother states: SATA
A. I need to begin sitz baths within 12 hours of birth if I have an episiotomy or a repaired laceration.
B. Tylenol is the preferred pain medication for breastfeeding mothers.
C. I should void spontaneously within 6-8 hours after birth.
D. I need an additional 1000 kcal/day as a breastfeeding mother. - Answer-A, B, D
Which of the following is NOT a symptom of a vaginal hematoma?
A. Normal-apprearing vulva with either no lacerations or normal-appearing, repaired
laceration/episiotomy.
B. Pain that is greater that expected for the client's circumstances.
C. A bluish mass protruding from the vagina.
D. Blood loss as indicated by lab results that is greater than expected based on EBL at delivery. - Answer-
C
What is the nurse's priority is a vaginal hematoma is suspected?
A. Apply ice to the perineum.
B. Apply a warm compress to the perineum.
,C. Monitor the bluish mass to determine whether it is enlarging.
D. Notify the provider. - Answer-D
The MOST reliable indicators of impending shock from early postpartum hemorrhage are: SATA
A. Blood pressure
B. Pulse
C. Urinary output
D. Level of consciousness - Answer-B, C, D
After completing all of the assessments on a postpartum client (BUBBLE LE), all of which were WDL, the
nurse performs orthostatic VS. The blood pressure decreased, and pulse increased by 20%, and the
client becomes dizzy and vomits. Temp is 99.3 and RR are 18. The nurse reviews the lab values below.
What is the priority in this scenario?
Pre delivery values are: hemoglobin: 10 hematocrit: 36% RBC: 5.2 WBC: 18,000
4 hrs after delivery (now): hemoglobin: 7.2 hematocrit: 23% RBC: 4.2 WBC: 20,000
A. Massage the fundus and administer oxytocin.
B. Notify the physician and recommend a blood transfusion.
C. Assess the client's temp and recommend blood cultures be ordered and drawn
D. Start an IV fluid boils with LR and notify HCP - Answer-D
A nurse is estimating blood loss on a postpartum client. The scales read 2.3 kg with a saturated pad and
chux. The dry weight of the pad and chux is 500 g. What is the blood loss in ml's? Report the number
only.
A. 130
B. 1,800
C. 1,300
D. 1.8 - Answer-B
, Upon examining a patient on day 2 after spontaneous vaginal delivery, a nurse finds the peri pad to be
completely saturated with bright red blood over the last hour. The priority in this scenario is:
A. Start a second IV line of normal saline
B. Notify the primary health care provider
C. Massage the fundus
D. Assess vital signs - Answer-C
The nurse takes a newborn to a primipara for a feeding. The mother holds the baby em face, strokes his
cheek, and states that this is the first newborn she has ever held. Which of the following assessments is
most appropriate?
A. Positive bonding and the client requires little teaching.
B. Poor bonding and referral to the social worker
C. Poor bonding but there is potential for positive mothering
D. Positive bonding but teaching related to newborn care is needed - Answer-D
After completing the Ballard Assessment, the nurse determines that infant's weight is at the 95%; height
95%; and head circumference at the 95%. What is the classification and what problem should the nurse
anticipate?
A. AGA, no apparent problem
B. SGA, hyperglycemia
C. LGA, hypoglycemia
D. Symmetrical IUGR, neurological deficits - Answer-C
Which of the following assessments would alert the nurse to complications associated with
hyperbilirubinemia?
A. Yellow sclera and head at 18 hours of birth
B. Elevated bilirubin level on day 3
A breastfeeding client is day 4 post Cesarean delivery. Current VS are temp. 99.8, RR 20, HR 88, and BP
118/60. What is the priority in this scenario?
A. Massage the fundus
B. Notify the physician
C. Reassess thr client's temp in 30 minutes
D. Assess the client's breasts for engorgement. - Answer-D
During a postpartum assessment, a cluster of hemorrhoids are noted in a G1P1 who delivered vaginally
with a superficial perineal laceration. Which of the following would be appropriate for the nurse to
include in the women's health teaching? SATA
A. The client should use a site bath three times a day for relief.
B. The client should apply a topical anesthetic as a relief measure.
C. The client should massage the hemorrhoids daily.
D. The client should be advised that the hemorrhoids will increase in size and number with each
subsequent pregnancy.
E. The client can use the side lying position to relieve pressure on the hemorrhoids.
F. The client should use witch hazel pads to soothe the area. - Answer-A, B, E, F
Which is the best intervention to help prevent development of postpartum thrombophlebitis after an
uncomplicated vaginal delivery?
A. Promote adequate oral fluid intake
B. Promote early and frequent ambulation
C. Place sequential compression devices on all patients
,D. Administer subcutaneous low molecular weight heparin - Answer-B
A G6 P4114 is 1/2 hour post spontaneous vaginal delivery of a 440 grams baby. Initially, which
complication should the nurse monitor considering this patient scenario?
A. Maternal hypoglycemia
B. Maternal hyperglycemia
C. Maternal VTE
D. Maternal uterine atony - Answer-D
The nurse is teaching a postpartum mother about changes in the postpartum period. The nurse
recognized the mother needs additional teaching when the mother states: SATA
A. I need to begin sitz baths within 12 hours of birth if I have an episiotomy or a repaired laceration.
B. Tylenol is the preferred pain medication for breastfeeding mothers.
C. I should void spontaneously within 6-8 hours after birth.
D. I need an additional 1000 kcal/day as a breastfeeding mother. - Answer-A, B, D
Which of the following is NOT a symptom of a vaginal hematoma?
A. Normal-apprearing vulva with either no lacerations or normal-appearing, repaired
laceration/episiotomy.
B. Pain that is greater that expected for the client's circumstances.
C. A bluish mass protruding from the vagina.
D. Blood loss as indicated by lab results that is greater than expected based on EBL at delivery. - Answer-
C
What is the nurse's priority is a vaginal hematoma is suspected?
A. Apply ice to the perineum.
B. Apply a warm compress to the perineum.
,C. Monitor the bluish mass to determine whether it is enlarging.
D. Notify the provider. - Answer-D
The MOST reliable indicators of impending shock from early postpartum hemorrhage are: SATA
A. Blood pressure
B. Pulse
C. Urinary output
D. Level of consciousness - Answer-B, C, D
After completing all of the assessments on a postpartum client (BUBBLE LE), all of which were WDL, the
nurse performs orthostatic VS. The blood pressure decreased, and pulse increased by 20%, and the
client becomes dizzy and vomits. Temp is 99.3 and RR are 18. The nurse reviews the lab values below.
What is the priority in this scenario?
Pre delivery values are: hemoglobin: 10 hematocrit: 36% RBC: 5.2 WBC: 18,000
4 hrs after delivery (now): hemoglobin: 7.2 hematocrit: 23% RBC: 4.2 WBC: 20,000
A. Massage the fundus and administer oxytocin.
B. Notify the physician and recommend a blood transfusion.
C. Assess the client's temp and recommend blood cultures be ordered and drawn
D. Start an IV fluid boils with LR and notify HCP - Answer-D
A nurse is estimating blood loss on a postpartum client. The scales read 2.3 kg with a saturated pad and
chux. The dry weight of the pad and chux is 500 g. What is the blood loss in ml's? Report the number
only.
A. 130
B. 1,800
C. 1,300
D. 1.8 - Answer-B
, Upon examining a patient on day 2 after spontaneous vaginal delivery, a nurse finds the peri pad to be
completely saturated with bright red blood over the last hour. The priority in this scenario is:
A. Start a second IV line of normal saline
B. Notify the primary health care provider
C. Massage the fundus
D. Assess vital signs - Answer-C
The nurse takes a newborn to a primipara for a feeding. The mother holds the baby em face, strokes his
cheek, and states that this is the first newborn she has ever held. Which of the following assessments is
most appropriate?
A. Positive bonding and the client requires little teaching.
B. Poor bonding and referral to the social worker
C. Poor bonding but there is potential for positive mothering
D. Positive bonding but teaching related to newborn care is needed - Answer-D
After completing the Ballard Assessment, the nurse determines that infant's weight is at the 95%; height
95%; and head circumference at the 95%. What is the classification and what problem should the nurse
anticipate?
A. AGA, no apparent problem
B. SGA, hyperglycemia
C. LGA, hypoglycemia
D. Symmetrical IUGR, neurological deficits - Answer-C
Which of the following assessments would alert the nurse to complications associated with
hyperbilirubinemia?
A. Yellow sclera and head at 18 hours of birth
B. Elevated bilirubin level on day 3
