Ricci Chapter 15 - Test Bank - 4th Edition || 100% Exact
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? Correct
Answer: At the level of the umbilcus
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 Correct 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? Correct 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? Correct 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? Correct 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? Correct "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? Correct 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. Correct 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? Correct 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 Correct 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 Correct 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? Correct "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? Correct 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 Correct 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
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? Correct
Answer: At the level of the umbilcus
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 Correct 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? Correct 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? Correct 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? Correct 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? Correct "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? Correct 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. Correct 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? Correct 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 Correct 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 Correct 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? Correct "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? Correct 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 Correct 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
