NSG 3500 - EXAM 3 TESTBANK WITH
CORRECT SOLUTIONS
A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella
vaccine at discharge. Which of the following must the nurse include in her discharge
teaching regarding the vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. Surgical masks must be worn by the mother when she holds the baby.
4. Antibodies transported through the breast milk will protect the baby. - ANSWER-1
1. This statement is correct.
2. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if
the woman becomes pregnant within 4 weeks of receiving the injection.
3. This is unnecessary. There is no risk to the baby whether the mother is bottle feeding
or breastfeeding.This statement is incorrect. There is no risk to the baby.
4. This statement is incorrect.
A 3-day-postpartum client questions why she is to receive the rubella vaccine before
leaving the hospital. Which of the following rationales should guide the nurse's
response?
1.The client's obstetric status is optimal for receiving the vaccine.
2. The client's immune system is highly responsive during the postpartum period.
3. The client's baby will be high risk for acquiring rubella if the woman does not
receive the vaccine.
4. The client's insurance company will pay for the shot if it is given during the
immediate postpartum period. - ANSWER-1
1 This statement is correct. Because the vaccine is teratogenic, the best time to
administer it is when the client is not pregnant.
This statement is incorrect. The immune systems of women during their pregnancies
and immediately postpartum are slightly depressed.
This statement is incorrect. The baby will be susceptible to rubella whether or not the
woman receives the vaccine.In general, insurance companies will pay for vaccinations
whenever they are needed.
A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of
100.2°F. Which of the following is the appropriate nursing intervention at this time?
1. Notify the doctor to get an order for acetaminophen.
2. Request an infectious disease consult from the doctor.
3. Provide the woman with cool compresses.
4. Encourage intake of water and other fluids. - ANSWER-4
1. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client
needs acetaminophen.
,2. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client is
infected.
3. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client
needs cool compresses.
4. It is likely that this client is dehydrated. She should be advised to drink fluids.
To prevent infection, the nurse teaches the postpartum client to perform which of the
following tasks?
1. Apply antibiotic ointment to the perineum daily.
2. Change the peripad at each voiding.
3. Void at least every two hours.
4. Spray the perineum with povidone-iodine after toileting. - ANSWER-2
1. It is unnecessary to apply antibiotic ointment to the perineum after delivery.
2. Clients should be advised to change their pads at each voiding.
3. The clients should void about every 2 hours, but this action is not an infection control
measure.
4. It is unnecessary to spray the perineum with a povidone-iodine solution. Plain water,
however, should be sprayed on the perineum.
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and
warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby
last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which
of the following actions should the nurse take at this time?
1. Encourage the woman exclusively to breastfeed her baby.
2. Have the woman massage her breasts hourly.
3. Obtain an order to culture her expressed breast milk.
4. Take the temperature and pulse rate of the woman. - ANSWER-1
Clients should be strongly encouraged exclusively to breastfeed their babies to prevent
engorgement.Massaging of the breast will stimulate more milk production. That is not
the best action to take.
It is unnecessary to culture the breast. This client is engorged; she does not have an
infection.It is unnecessary to assess this client's temperature and pulse rate. This client
is engorged; she is not infected.
A breastfeeding woman has been counseled on how to prevent engorgement. Which of
the following actions by the mother shows that the teaching was effective?
1. She pumps her breasts after each feeding.
2. She feeds her baby every 2 to 3 hours.
3. She feeds her baby 10 minutes on each side.
4. She supplements each feeding with formula. - ANSWER-2
Clients are not recommended to pump their breasts after feedings unless there is a
specific reason to do so.This statement is true. The best way to prevent engorgement is
to feed the baby every 2 to 3 hours.
Clients should not restrict babies' feeding times. Babies feed at different rates. Babies
themselves, therefore, should regulate the amount of time they need to complete their
feeds.
,Clients are not recommended to supplement with formula unless there is a specific
reason to do so.
A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go
on a diet?" Which of the following responses is appropriate?
1. "It is fine for you to start dieting right now as long as you drink plenty of milk."
2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding."
3. "You must eat at least 3,000 calories per day in order to produce enough milk for
your baby."
4. "Many mothers lose weight when they breastfeed because the baby consumes
about 600 calories a day." - ANSWER-4
It is not recommended that breastfeeding mothers go on weight-reduction diets. In
addition, it is not necessary for mothers to drink milk to make breast milk.
When a breastfeeding woman has a poor diet, the quality of her breast milk changes
very little. In fact, if a mother consumes a poor diet, it is her own body that will suffer.
Mothers do not need to eat 3,000 calories a day while breastfeeding.
Many mothers who consume approximately the same number of calories while
breastfeeding as they did when they were pregnant do lose weight while breastfeeding.
A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is
assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia
rubra, and perineal sutures are intact. Which of the following actions should the nurse
take at this time?
1. Do nothing. This is a normal finding.
2. Massage the woman's fundus.
3. Take the woman to the bathroom to void.
4. Notify the woman's primary healthcare provider. - ANSWER-4
A client who is 3 days postpartum asks the nurse, "When may my husband and I begin
having sexual relations again?" The nurse should encourage the couple to wait until
after which of the following has occurred?
1. The client has had her six-week postpartum checkup.
2. The episiotomy has healed and the lochia has stopped.
3. The lochia has turned to pink and the vagina is no longer tender.
4. The client has had her first postpartum menstrual period. - ANSWER-1
A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse
that when she and her husband had intercourse for the first time after the delivery, "I
couldn't stand it. It was so painful. The doctor must have done something terrible to my
vagina." Which of the following responses by the nurse is appropriate?
1. "After a delivery the vagina is always very tender. It should feel better the next time
you have intercourse."
2. "Does your baby have thrush? If so, you should be assessed for a yeast infection in
your vagina."
3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy
your discomfort."
, 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in to be
checked?" - ANSWER-3
The nurse monitors his or her postpartum clients carefully because which of the
following physiological changes occurs during the early postpartum period?
1. Decreased urinary output.
2. Increased blood pressure.
3. Decreased blood volume.
4. Increased estrogen level. - ANSWER-3
A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no
other complaints. Which of the following actions by the nurse is appropriate?
1. Take the woman's temperature.
2. Advise the woman to decrease her fluid intake.
3. Reassure the woman that this is normal.
4. Notify the neonate's pediatrician. - ANSWER-3
A client informs the nurse that she intends to bottle feed her baby. Which of the
following actions should the nurse encourage the client to perform? Select all that apply.
1. Increase her fluid intake for a few days.
2. Massage her breasts every 4 hours.
3. Apply heat packs to her axillae.
4. Wear a supportive bra 24 hours a day.
5. Stand with her back toward the shower water. - ANSWER-4 and 5 are correct.
It is unnecessary for a bottle-feeding mother to increase her fluid intake.
It is inadvisable for a bottle-feeding mother to massage her breasts.
It is inadvisable for a bottle-feeding mother to apply heat to her breasts.
The mother should be advised to wear a supportive bra 24 hours a day for a week or
so.
The mother should be advised to stand with her back toward the warm shower water.
The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother
of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch.
Which of the following is the best action for the nurse to advise the client to perform?
1. Intermittently apply ice packs to her axillae and breasts.
2. Apply lanolin to her breasts and nipples every 3 hours.
3. Express milk from the breasts every 3 hours.
4. Ask the primary healthcare provider to order a milk suppressant. - ANSWER-1
A multigravid, postpartum woman reports severe abdominal cramping whenever she
nurses her baby. Which of the following responses by the nurse is appropriate?
1. Suggest that the woman bottle feed for a few days.
2. Instruct the patient on how to massage her fundus.
3. Instruct the patient to feed using an alternate position.
4. Discuss the action of breastfeeding hormones. - ANSWER-4
CORRECT SOLUTIONS
A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella
vaccine at discharge. Which of the following must the nurse include in her discharge
teaching regarding the vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. Surgical masks must be worn by the mother when she holds the baby.
4. Antibodies transported through the breast milk will protect the baby. - ANSWER-1
1. This statement is correct.
2. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if
the woman becomes pregnant within 4 weeks of receiving the injection.
3. This is unnecessary. There is no risk to the baby whether the mother is bottle feeding
or breastfeeding.This statement is incorrect. There is no risk to the baby.
4. This statement is incorrect.
A 3-day-postpartum client questions why she is to receive the rubella vaccine before
leaving the hospital. Which of the following rationales should guide the nurse's
response?
1.The client's obstetric status is optimal for receiving the vaccine.
2. The client's immune system is highly responsive during the postpartum period.
3. The client's baby will be high risk for acquiring rubella if the woman does not
receive the vaccine.
4. The client's insurance company will pay for the shot if it is given during the
immediate postpartum period. - ANSWER-1
1 This statement is correct. Because the vaccine is teratogenic, the best time to
administer it is when the client is not pregnant.
This statement is incorrect. The immune systems of women during their pregnancies
and immediately postpartum are slightly depressed.
This statement is incorrect. The baby will be susceptible to rubella whether or not the
woman receives the vaccine.In general, insurance companies will pay for vaccinations
whenever they are needed.
A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of
100.2°F. Which of the following is the appropriate nursing intervention at this time?
1. Notify the doctor to get an order for acetaminophen.
2. Request an infectious disease consult from the doctor.
3. Provide the woman with cool compresses.
4. Encourage intake of water and other fluids. - ANSWER-4
1. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client
needs acetaminophen.
,2. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client is
infected.
3. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client
needs cool compresses.
4. It is likely that this client is dehydrated. She should be advised to drink fluids.
To prevent infection, the nurse teaches the postpartum client to perform which of the
following tasks?
1. Apply antibiotic ointment to the perineum daily.
2. Change the peripad at each voiding.
3. Void at least every two hours.
4. Spray the perineum with povidone-iodine after toileting. - ANSWER-2
1. It is unnecessary to apply antibiotic ointment to the perineum after delivery.
2. Clients should be advised to change their pads at each voiding.
3. The clients should void about every 2 hours, but this action is not an infection control
measure.
4. It is unnecessary to spray the perineum with a povidone-iodine solution. Plain water,
however, should be sprayed on the perineum.
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and
warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby
last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which
of the following actions should the nurse take at this time?
1. Encourage the woman exclusively to breastfeed her baby.
2. Have the woman massage her breasts hourly.
3. Obtain an order to culture her expressed breast milk.
4. Take the temperature and pulse rate of the woman. - ANSWER-1
Clients should be strongly encouraged exclusively to breastfeed their babies to prevent
engorgement.Massaging of the breast will stimulate more milk production. That is not
the best action to take.
It is unnecessary to culture the breast. This client is engorged; she does not have an
infection.It is unnecessary to assess this client's temperature and pulse rate. This client
is engorged; she is not infected.
A breastfeeding woman has been counseled on how to prevent engorgement. Which of
the following actions by the mother shows that the teaching was effective?
1. She pumps her breasts after each feeding.
2. She feeds her baby every 2 to 3 hours.
3. She feeds her baby 10 minutes on each side.
4. She supplements each feeding with formula. - ANSWER-2
Clients are not recommended to pump their breasts after feedings unless there is a
specific reason to do so.This statement is true. The best way to prevent engorgement is
to feed the baby every 2 to 3 hours.
Clients should not restrict babies' feeding times. Babies feed at different rates. Babies
themselves, therefore, should regulate the amount of time they need to complete their
feeds.
,Clients are not recommended to supplement with formula unless there is a specific
reason to do so.
A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go
on a diet?" Which of the following responses is appropriate?
1. "It is fine for you to start dieting right now as long as you drink plenty of milk."
2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding."
3. "You must eat at least 3,000 calories per day in order to produce enough milk for
your baby."
4. "Many mothers lose weight when they breastfeed because the baby consumes
about 600 calories a day." - ANSWER-4
It is not recommended that breastfeeding mothers go on weight-reduction diets. In
addition, it is not necessary for mothers to drink milk to make breast milk.
When a breastfeeding woman has a poor diet, the quality of her breast milk changes
very little. In fact, if a mother consumes a poor diet, it is her own body that will suffer.
Mothers do not need to eat 3,000 calories a day while breastfeeding.
Many mothers who consume approximately the same number of calories while
breastfeeding as they did when they were pregnant do lose weight while breastfeeding.
A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is
assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia
rubra, and perineal sutures are intact. Which of the following actions should the nurse
take at this time?
1. Do nothing. This is a normal finding.
2. Massage the woman's fundus.
3. Take the woman to the bathroom to void.
4. Notify the woman's primary healthcare provider. - ANSWER-4
A client who is 3 days postpartum asks the nurse, "When may my husband and I begin
having sexual relations again?" The nurse should encourage the couple to wait until
after which of the following has occurred?
1. The client has had her six-week postpartum checkup.
2. The episiotomy has healed and the lochia has stopped.
3. The lochia has turned to pink and the vagina is no longer tender.
4. The client has had her first postpartum menstrual period. - ANSWER-1
A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse
that when she and her husband had intercourse for the first time after the delivery, "I
couldn't stand it. It was so painful. The doctor must have done something terrible to my
vagina." Which of the following responses by the nurse is appropriate?
1. "After a delivery the vagina is always very tender. It should feel better the next time
you have intercourse."
2. "Does your baby have thrush? If so, you should be assessed for a yeast infection in
your vagina."
3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy
your discomfort."
, 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in to be
checked?" - ANSWER-3
The nurse monitors his or her postpartum clients carefully because which of the
following physiological changes occurs during the early postpartum period?
1. Decreased urinary output.
2. Increased blood pressure.
3. Decreased blood volume.
4. Increased estrogen level. - ANSWER-3
A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no
other complaints. Which of the following actions by the nurse is appropriate?
1. Take the woman's temperature.
2. Advise the woman to decrease her fluid intake.
3. Reassure the woman that this is normal.
4. Notify the neonate's pediatrician. - ANSWER-3
A client informs the nurse that she intends to bottle feed her baby. Which of the
following actions should the nurse encourage the client to perform? Select all that apply.
1. Increase her fluid intake for a few days.
2. Massage her breasts every 4 hours.
3. Apply heat packs to her axillae.
4. Wear a supportive bra 24 hours a day.
5. Stand with her back toward the shower water. - ANSWER-4 and 5 are correct.
It is unnecessary for a bottle-feeding mother to increase her fluid intake.
It is inadvisable for a bottle-feeding mother to massage her breasts.
It is inadvisable for a bottle-feeding mother to apply heat to her breasts.
The mother should be advised to wear a supportive bra 24 hours a day for a week or
so.
The mother should be advised to stand with her back toward the warm shower water.
The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother
of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch.
Which of the following is the best action for the nurse to advise the client to perform?
1. Intermittently apply ice packs to her axillae and breasts.
2. Apply lanolin to her breasts and nipples every 3 hours.
3. Express milk from the breasts every 3 hours.
4. Ask the primary healthcare provider to order a milk suppressant. - ANSWER-1
A multigravid, postpartum woman reports severe abdominal cramping whenever she
nurses her baby. Which of the following responses by the nurse is appropriate?
1. Suggest that the woman bottle feed for a few days.
2. Instruct the patient on how to massage her fundus.
3. Instruct the patient to feed using an alternate position.
4. Discuss the action of breastfeeding hormones. - ANSWER-4
