Chapter 20 Maternal-child nursing Exam 2024

Chapter 20 Maternal-child nursing Exam 2024 A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurse's best response is a. "You have pitting edema in your ankles." b. "You have deep tendon reflexes rated 2+." c. "You have calf pain when I flexed your foot." d. "You have a 'fleshy' odor to your vaginal drainage." -Answer-C Which woman is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who has started to breastfeed -Answer-A Which maternal event is abnormal in the early postpartum period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba -Answer-D Which finding 12 hours after birth requires further assessment? a. The fundus is palpable two fingerbreadths above the umbilicus. b. The fundus is palpable at the level of the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus. -Answer-A If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, the nurse should a. tell the physician immediately. b. have the laboratory draw blood for reanalysis. c. recognize that this is an acceptable range at this point. d. begin antibiotic therapy immediately. -Answer-C Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Postpartum hemorrhage and eclampsia b. Fever and increased blood pressure c. Postpartum hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture -Answer-C A postpartum patient asks, "Will these stretch marks go away?" The nurse's best response is a. "They will fade and be gone by your 6-week checkup." b. "No, unfortunately they will never fade away." c. "Yes, eventually they will totally disappear." d. "They will fade to silvery lines but won't disappear completely." -Answer-D A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after delivery because of a. increased estrogen. b. increased progesterone. c. decreased melanocyte-stimulating hormone. d. decreased human placental lactogen. -Answer-C If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the patient has a. been lying on her right side too long. b. a distended bladder. c. stretched ligaments that are unable to support the uterus. d. a normal involution. -Answer-B A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a. The woman is a gravida 2, para 2. b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy. -Answer-D Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh-, baby Rh+ b. Mother Rh-, baby Rh- c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh- -Answer-A If rubella vaccine is indicated for a postpartum patient, instructions to the patient should include a. drinking plenty of fluids to prevent fever. b. no specific instructions. c. recommending that she stop breastfeeding for 24 hours after injection. d. explaining the risks of becoming pregnant within 1 month after injection. -Answer-D Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the provider of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder. -Answer-D When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is a. rectal suppositories. b. early and frequent ambulation. c. tightening and relaxing abdominal muscles. d. providing carbonated beverages. -Answer-B