Ricci Chapter 15, And Chapter 16 -Test
Bank - 4th Edition Questions and
Correct Answers.
1. A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse
palpates the client's fundus. Which finding would the nurse identify as expected? - Answer :
At the level of the umbilicus
Rationale: During the first 12 hours postpartum, the fundus of the uterus is located at the level
of the umbilicus
2. When caring for a mother who has had a cesarean birth, the nurse would expect the client's
lochia to be - Answer : less than after a vaginal birth.
Rationale: Women who have had cesarean births tend to have less flow because the uterine
debris is removed manually along with delivery of the placenta.
3. The nurse is developing a teaching plan for a client who has decided to bottle-feed her
newborn. Which information would the nurse include in the teaching plan to facilitate
suppression of lactation? - Answer Answer: instructing her to apply ice packs to both breasts
every other hour
4. The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which
finding would the nurse expect when assessing the client's fundus? - Answer : cannot be
palpated
Rationale: By the end of 10 days, the fundus usually cannot be palpated because it has
descended
into the true pelvis.
6. When the nurse is assessing a postpartum client approximately 6 hours after birth, which
finding would warrant further investigation? - Answer blood pressure 90/50 mm Hg
7. A postpartum client who is bottle feeding her newborn asks, "When should my period
return?"
Which response by the nurse would be most appropriate? - Answer "It varies, but you can
estimate it returning in about 7 to 9 weeks."
8. A nurse is providing care to a postpartum woman. The nurse determines that the client is in
the
,taking-in phase based on which finding? - Answer The client states, "He has my eyes and
nose."
10. A postpartum client comes to the clinic for her 6-week postpartum checkup. When
assessing
the client's cervix, the nurse would expect the external cervical os to appear:
A. shapeless.
B. circular.
C. triangular.
D. slit-like. - Answer Answer: D
Rationale: After birth, the external cervical os is no longer shaped like a circle but instead
appears as a jagged slit-like opening, often described as a "fish mouth."
11. A nurse is teaching a postpartum client how to do muscle-clenching exercises for the
perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason
would
the nurse most likely incorporate into the response? - Answer improves pelvic floor tone
12. A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm
going to do the best I can for my son." The nurse interprets this as indicating the father is in
which stage of adaptation?
A. expectations
B. transition to mastery
C. reality
D. taking-in - Answer Answer: B
Rationale: The father's statement reflects transition to mastery because he is making a
conscious
decision to take control and be at the center of the newborn's life regardless of his
preparedness. The expectations stage involves preconceptions about how life will be with a
newborn. Reality
occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal
adaptation.
13. A postpartum client is experiencing subinvolution. When reviewing the woman's labor and
birth history, which factor would the nurse identify as being a significant contributor to this
condition?
A. early ambulation
,B. short duration of labor
C. breastfeeding
D. use of anesthetics - Answer Answer: D
Rationale: Factors that inhibit involution include prolonged labor and difficult birth, incomplete
expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine
muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which
displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine
muscles),
and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion
of amniotic membranes and placenta at birth, complication-free labor and birth process,
breastfeeding, and early ambulation.
14. A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the
past several hours." Which response by the nurse would be most appropriate? - Answer
"Your body is undergoing many changes that cause your bladder to fill quickly."
15. The nurse develops a teaching plan for a postpartum client and includes teaching about how
to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information
for which reason? - Answer improve pelvic floor tone
16. When assessing a postpartum woman, the nurse suspects the woman is experiencing a
problem based on which finding?
A. elevated white blood cell count
B. acute decrease in hematocrit
C. increased levels of clotting factors
D. pulse rate of 60 beats/minute - Answer Answer: B
Rationale: Despite a decrease in blood volume after birth, hematocrit levels remain relatively
stable and may even increase. An acute decrease is not an expected finding. Red blood cell
production ceases early in the puerperium, causing mean hemoglobin and hematocrit levels to
decrease slightly in the first 24 hours. During the next 2 weeks, both levels rise slowly. The
white blood count, which increases in labor, remains elevated for first 4 to 6 days after birth but
then falls to 6,000 to 10,000/mm3. The WBC count remains elevated for the first 4 to 6 days and
clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for
the
first two weeks reflects the decrease in cardiac output. The increase in cardiac output and
stroke
, volume during pregnancy begins to diminish after birth once the placenta has been delivered.
This decrease in cardiac output is reflected in bradycardia (40 to 60 bpm) for up to the first 2
weeks postpartum.
19. A nurse is assessing a postpartum woman's adjustment to her maternal role. Which event
would the nurse expect to occur first?
A. reestablishing relationships with others
B. demonstrating increasing confidence in care of the newborn
C. assuming a passive role in meeting her own needs
D. becoming preoccupied with the present - Answer Answer: C
Rationale: The first task of adjusting to the maternal role is the taking-in phase in which the
mother demonstrates dependent behaviors and assumes a passive role in meeting own basic
needs. During the taking-hold phase, the mother becomes preoccupied with the present.
During
the letting-go phase, the mother reestablishes relationships with others and demonstrates
increased responsibility and confidence in caring for the newborn.
20. The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want
to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets
this as indicating which stage?
A. expectations
B. reality
C. transition to mastery
D. taking-hold - Answer Answer: B
Rationale: The partner's statement reflects stage 2 (reality), which occurs when fathers or
partners realize that their expectations in stage 1 are not realistic. Their feelings change from
elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the
newborn's care and yet do not feel prepared to do so. New fathers or partners pass through
stage
1 (expectations) with preconceptions about what home life will be like with a newborn. Many
men may be unaware of the dramatic changes that can occur when this newborn comes home
to
live with them. In stage 3 (transition to mastery), the father or partner makes a conscious
decision to take control and be at the center of his newborn's life regardless of his
preparedness.
Taking-hold is a stage of maternal adaptation.
Bank - 4th Edition Questions and
Correct Answers.
1. A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse
palpates the client's fundus. Which finding would the nurse identify as expected? - Answer :
At the level of the umbilicus
Rationale: During the first 12 hours postpartum, the fundus of the uterus is located at the level
of the umbilicus
2. When caring for a mother who has had a cesarean birth, the nurse would expect the client's
lochia to be - Answer : less than after a vaginal birth.
Rationale: Women who have had cesarean births tend to have less flow because the uterine
debris is removed manually along with delivery of the placenta.
3. The nurse is developing a teaching plan for a client who has decided to bottle-feed her
newborn. Which information would the nurse include in the teaching plan to facilitate
suppression of lactation? - Answer Answer: instructing her to apply ice packs to both breasts
every other hour
4. The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which
finding would the nurse expect when assessing the client's fundus? - Answer : cannot be
palpated
Rationale: By the end of 10 days, the fundus usually cannot be palpated because it has
descended
into the true pelvis.
6. When the nurse is assessing a postpartum client approximately 6 hours after birth, which
finding would warrant further investigation? - Answer blood pressure 90/50 mm Hg
7. A postpartum client who is bottle feeding her newborn asks, "When should my period
return?"
Which response by the nurse would be most appropriate? - Answer "It varies, but you can
estimate it returning in about 7 to 9 weeks."
8. A nurse is providing care to a postpartum woman. The nurse determines that the client is in
the
,taking-in phase based on which finding? - Answer The client states, "He has my eyes and
nose."
10. A postpartum client comes to the clinic for her 6-week postpartum checkup. When
assessing
the client's cervix, the nurse would expect the external cervical os to appear:
A. shapeless.
B. circular.
C. triangular.
D. slit-like. - Answer Answer: D
Rationale: After birth, the external cervical os is no longer shaped like a circle but instead
appears as a jagged slit-like opening, often described as a "fish mouth."
11. A nurse is teaching a postpartum client how to do muscle-clenching exercises for the
perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason
would
the nurse most likely incorporate into the response? - Answer improves pelvic floor tone
12. A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm
going to do the best I can for my son." The nurse interprets this as indicating the father is in
which stage of adaptation?
A. expectations
B. transition to mastery
C. reality
D. taking-in - Answer Answer: B
Rationale: The father's statement reflects transition to mastery because he is making a
conscious
decision to take control and be at the center of the newborn's life regardless of his
preparedness. The expectations stage involves preconceptions about how life will be with a
newborn. Reality
occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal
adaptation.
13. A postpartum client is experiencing subinvolution. When reviewing the woman's labor and
birth history, which factor would the nurse identify as being a significant contributor to this
condition?
A. early ambulation
,B. short duration of labor
C. breastfeeding
D. use of anesthetics - Answer Answer: D
Rationale: Factors that inhibit involution include prolonged labor and difficult birth, incomplete
expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine
muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which
displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine
muscles),
and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion
of amniotic membranes and placenta at birth, complication-free labor and birth process,
breastfeeding, and early ambulation.
14. A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the
past several hours." Which response by the nurse would be most appropriate? - Answer
"Your body is undergoing many changes that cause your bladder to fill quickly."
15. The nurse develops a teaching plan for a postpartum client and includes teaching about how
to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information
for which reason? - Answer improve pelvic floor tone
16. When assessing a postpartum woman, the nurse suspects the woman is experiencing a
problem based on which finding?
A. elevated white blood cell count
B. acute decrease in hematocrit
C. increased levels of clotting factors
D. pulse rate of 60 beats/minute - Answer Answer: B
Rationale: Despite a decrease in blood volume after birth, hematocrit levels remain relatively
stable and may even increase. An acute decrease is not an expected finding. Red blood cell
production ceases early in the puerperium, causing mean hemoglobin and hematocrit levels to
decrease slightly in the first 24 hours. During the next 2 weeks, both levels rise slowly. The
white blood count, which increases in labor, remains elevated for first 4 to 6 days after birth but
then falls to 6,000 to 10,000/mm3. The WBC count remains elevated for the first 4 to 6 days and
clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for
the
first two weeks reflects the decrease in cardiac output. The increase in cardiac output and
stroke
, volume during pregnancy begins to diminish after birth once the placenta has been delivered.
This decrease in cardiac output is reflected in bradycardia (40 to 60 bpm) for up to the first 2
weeks postpartum.
19. A nurse is assessing a postpartum woman's adjustment to her maternal role. Which event
would the nurse expect to occur first?
A. reestablishing relationships with others
B. demonstrating increasing confidence in care of the newborn
C. assuming a passive role in meeting her own needs
D. becoming preoccupied with the present - Answer Answer: C
Rationale: The first task of adjusting to the maternal role is the taking-in phase in which the
mother demonstrates dependent behaviors and assumes a passive role in meeting own basic
needs. During the taking-hold phase, the mother becomes preoccupied with the present.
During
the letting-go phase, the mother reestablishes relationships with others and demonstrates
increased responsibility and confidence in caring for the newborn.
20. The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want
to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets
this as indicating which stage?
A. expectations
B. reality
C. transition to mastery
D. taking-hold - Answer Answer: B
Rationale: The partner's statement reflects stage 2 (reality), which occurs when fathers or
partners realize that their expectations in stage 1 are not realistic. Their feelings change from
elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the
newborn's care and yet do not feel prepared to do so. New fathers or partners pass through
stage
1 (expectations) with preconceptions about what home life will be like with a newborn. Many
men may be unaware of the dramatic changes that can occur when this newborn comes home
to
live with them. In stage 3 (transition to mastery), the father or partner makes a conscious
decision to take control and be at the center of his newborn's life regardless of his
preparedness.
Taking-hold is a stage of maternal adaptation.
