Ricci Chapter 16 - Test Bank - 4th Edition
questions and answers A+ updated
1. A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during
pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should
the nurse take?
A. Document the finding, as it is a normal finding at this time.
B. Contact the primary care provider, as it indicates early DIC.
C. Contact the primary care provider, as it is a first sign of postpartum eclampsia.
D. Obtain a prescription for a CBC, as it suggests postpartum anemia. - correct answer
✔✔Answer: A
Rationale: Pulse rates of 60 to 80 beats per minute at rest are normal during the first week after
birth. This pulse rate is called puerperal bradycardia.
2. A client who has just given birth to a healthy newborn required an episiotomy. Which action
would the nurse implement immediately after birth to decrease the client's pain from the
procedure?
A. Offer warm blankets.
B. Encourage the woman to void.
C. Apply an ice pack to the site.
D. Offer a warm sitz bath. - correct answer ✔✔Answer: C
Rationale: An ice pack is the first measure used after a vaginal birth to provide perineal comfort
from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that
the
woman may experience. Encouraging her to void promotes urinary elimination and uterine
,involution. A warm sitz bath is effective after the first 24 hours.
3. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which
medication to be prescribed?
A. ferrous sulfate
B. methylergonovine
C. docusate
D. bromocriptine - correct answer ✔✔Answer: C
Rationale: A stool softener such as docusate may promote bowel elimination in a woman with a
fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate
would be used to treat anemia. However, it is associated with constipation and would increase
the discomfort when the woman has a bowel movement. Methylergonovine would be used to
prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.
4. A nurse is observing a new mother interacting with her newborn. Which statement would
alert
the nurse to the potential for impaired bonding between mother and newborn?
A. "You have your daddy's eyes."
B. "He looks like a frog to me."
C. "Where did you get all that hair?"
D. "He seems to sleep a lot." - correct answer ✔✔Answer: B
Rationale: Negative comments may indicate impaired bonding. Pointing out commonalities such
as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors.
The statement about sleeping a lot indicates that the mother is assigning meaning to the
newborn's actions, another positive attachment behavior.
, 5. After a normal labor and birth, a client is discharged from the hospital 12 hours later. When
the community health nurse makes a home visit 2 days later, which finding would alert the
nurse
to the need for further intervention?
A. presence of lochia serosa
B. frequent scant voidings
C. fundus firm, below umbilicus
D. milk filling in both breasts - correct answer ✔✔Answer: B
Rationale: Infrequent or insufficient voiding may be a sign of infection and is not a normal
finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and
milk filling the breasts are expected findings.
6. A primipara client who is bottle feeding her baby begins to experience breast engorgement
on
her third postpartum day. Which instruction by the nurse would be most appropriate to aid in
relieving her discomfort?
A. "Express some milk from your breasts every so often to relieve the distention."
B. "Remove your bra to relieve the pressure on your sensitive nipples and breasts."
C. "Apply ice packs to your breasts to reduce the amount of milk being produced."
D. "Take several warm showers daily to stimulate the milk let-down reflex." - correct answer
✔✔Answer: C
Rationale: For the woman with breast engorgement who is bottle feeding her newborn,
encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts
and taking warm showers would be appropriate for the woman who was breastfeeding.
Wearing
a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle
feeding.
questions and answers A+ updated
1. A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during
pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should
the nurse take?
A. Document the finding, as it is a normal finding at this time.
B. Contact the primary care provider, as it indicates early DIC.
C. Contact the primary care provider, as it is a first sign of postpartum eclampsia.
D. Obtain a prescription for a CBC, as it suggests postpartum anemia. - correct answer
✔✔Answer: A
Rationale: Pulse rates of 60 to 80 beats per minute at rest are normal during the first week after
birth. This pulse rate is called puerperal bradycardia.
2. A client who has just given birth to a healthy newborn required an episiotomy. Which action
would the nurse implement immediately after birth to decrease the client's pain from the
procedure?
A. Offer warm blankets.
B. Encourage the woman to void.
C. Apply an ice pack to the site.
D. Offer a warm sitz bath. - correct answer ✔✔Answer: C
Rationale: An ice pack is the first measure used after a vaginal birth to provide perineal comfort
from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that
the
woman may experience. Encouraging her to void promotes urinary elimination and uterine
,involution. A warm sitz bath is effective after the first 24 hours.
3. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which
medication to be prescribed?
A. ferrous sulfate
B. methylergonovine
C. docusate
D. bromocriptine - correct answer ✔✔Answer: C
Rationale: A stool softener such as docusate may promote bowel elimination in a woman with a
fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate
would be used to treat anemia. However, it is associated with constipation and would increase
the discomfort when the woman has a bowel movement. Methylergonovine would be used to
prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.
4. A nurse is observing a new mother interacting with her newborn. Which statement would
alert
the nurse to the potential for impaired bonding between mother and newborn?
A. "You have your daddy's eyes."
B. "He looks like a frog to me."
C. "Where did you get all that hair?"
D. "He seems to sleep a lot." - correct answer ✔✔Answer: B
Rationale: Negative comments may indicate impaired bonding. Pointing out commonalities such
as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors.
The statement about sleeping a lot indicates that the mother is assigning meaning to the
newborn's actions, another positive attachment behavior.
, 5. After a normal labor and birth, a client is discharged from the hospital 12 hours later. When
the community health nurse makes a home visit 2 days later, which finding would alert the
nurse
to the need for further intervention?
A. presence of lochia serosa
B. frequent scant voidings
C. fundus firm, below umbilicus
D. milk filling in both breasts - correct answer ✔✔Answer: B
Rationale: Infrequent or insufficient voiding may be a sign of infection and is not a normal
finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and
milk filling the breasts are expected findings.
6. A primipara client who is bottle feeding her baby begins to experience breast engorgement
on
her third postpartum day. Which instruction by the nurse would be most appropriate to aid in
relieving her discomfort?
A. "Express some milk from your breasts every so often to relieve the distention."
B. "Remove your bra to relieve the pressure on your sensitive nipples and breasts."
C. "Apply ice packs to your breasts to reduce the amount of milk being produced."
D. "Take several warm showers daily to stimulate the milk let-down reflex." - correct answer
✔✔Answer: C
Rationale: For the woman with breast engorgement who is bottle feeding her newborn,
encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts
and taking warm showers would be appropriate for the woman who was breastfeeding.
Wearing
a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle
feeding.
