NUR 1600 Postpartum Exam Review

NUR 1600 Postpartum Exam Review Question 1 See full question A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client? You Selected: • "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." Correct response: • "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." Explanation: Discussing the childbirth experience helps the client acknowledge and understand what happened during this event. The nurse should give the client a chance to ask questions about the event and seek clarification, if needed. After the client discusses the event, she may be able to shift the focus away from herself and begin the tasks that will help her assume the maternal role. The nurse must determine the client's understanding of her physical needs and those of her neonate after teaching and demonstrating care techniques; discussing the childbirth experience won't help her to meet these needs. Remediation: • Discharge Planning, Neonatal Question 2 See full question A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to: You Selected: • discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. Correct response: • discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. Question 3 See full question A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? You Selected: • Use a warm moist compress over the painful area. Correct response: • Use a warm moist compress over the painful area. Explanation: Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding does not have to be interrupted. The client will also need to pump the breast to keep the breast empty of milk and to ensure an adequate milk supply. Adequate emptying of the affected breast helps prevent more bacteria from collecting in the breast and may shorten the duration of the infection. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside. Remediation: Question 4 See full question Which measure included in the care plan for a client in the fourth stage of labor requires revision? You Selected: • Obtain an order for catheterization to protect the bladder from trauma. Correct response: • Obtain an order for catheterization to protect the bladder from trauma. Explanation: Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the care plan during the fourth stage of labor. Remediation: Question 5 See full question A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? You Selected: • Discuss the unit's policy with the charge nurse. Correct response: • Discuss the unit's policy with the charge nurse. Explanation: Remediation: Question 6 See full question After the first breastfeeding, the client asks the nurse, “How often should I try to breastfeed?” What frequency should the nurse recommend? You Selected: • every 2 to 3 hours for the first 48 hours Correct response: • every 2 to 3 hours for the first 48 hours Explanation: Soon after giving birth, the client should breastfeed every 2 to 3 hours until her milk supply is established. Remediation: Question 7 See full question While assessing a primipara during the immediate postpartum period, the nurse plans to use both hands to assess the client's fundus to: You Selected: • promote uterine involution. Correct response: • prevent uterine inversion. Explanation: Using both hands to assess the fundus is useful for the prevention of uterine inversion. With one hand, the nurse should support the position of the lower uterus and cervix, while palpating the fundus with the other hand. Using both hands does not hasten or promote uterine involution, which lasts about 6 weeks from the time of childbirth. Using both hands to assess the fundus will not hasten the puerperium period. Determining the size of the fundus may be important if the client is experiencing excessive lochia because an enlarged fundus may be an indicator of retained blood clots or placenta fragments. The nurse, though, does not need to use both hands to determine this. Remediation: Question 8 See full question The nurse from the nursery is bringing a newborn to a mother’s room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which action to ensure the safest transition of the infant to the mother? You Selected: • Complete the hospital identification procedure with mother and infant. Correct response: • Complete the hospital identification procedure with mother and infant. Explanation: Remediation: Question 9 See full question Which client statement indicates effective teaching about burping a breastfed neonate? You Selected: • “When I switch to the other breast, I’ll burp the baby.” Correct response: • “When I switch to the other breast, I’ll burp the baby.” Explanation: Remediation: Question 10 See full question During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? You Selected: • Express a small amount of breast milk. Correct response: • Express a small amount of breast milk. Explanation: Remediation: Question 11 See full question Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? You Selected: • “Gradually eliminate one feeding at a time.” Correct response: • “Gradually eliminate one feeding at a time.” Explanation: Remediation: Question 12 See full question Four hours after cesarean birth of a neonate weighing 8 lb, 13 oz (4,000 g), the primiparous client asks, “If I get pregnant again, will I need to have a cesarean?” When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which standard of practice? You Selected: • VBAC may be possible if the client has not had a classic uterine incision. Correct response: • VBAC may be possible if the client has not had a classic uterine incision. Explanation: VBAC can be attempted if the client has not had a classic uterine incision. This type of incision carries a danger of uterine rupture. A health care provider (HCP) must be available, and a cesarean birth must be possible within 30 minutes. A history of rapid labor is not a criterion for VBAC. A low transverse incision is not a contraindication for VBAC. A classic (vertical) incision is a contraindication because the client has a greater possibility for uterine rupture. Estimated fetal weight greater than 4,000 g by itself is not a contraindication if the mother is not diabetic. Remediation: • Cesarean Birth Postoperative Care Question 13 See full question A multiparous client at 24 hours postpartum is found to have a swelling and pain in her right leg. She demonstrates a positive Homan sign with discomfort. The nurse should: You Selected: • notify the client’s health care provider (HCP) immediately Correct response: • notify the client’s health care provider (HCP) immediately Explanation: A pain and swelling may be indicative of thrombophlebitis. Redness at the site and may be more reliable as an indicator of thrombophlebitis. The nurse should notify the HCP immediately and ask the client to remain in bed to minimize the risk for pulmonary embolus, a serious consequence of thrombophlebitis should a clot dislodge. Placing an ice pack on the perineal area is inappropriate. However, ice to the perineum would be useful for episiotomy pain and swelling. The client does not need to be positioned in semi-Fowler’s position but should remain on bed rest to prevent dislodgement of a potential clot. Remediation: Question 14 See full question A primiparous client who is beginning to breastfeed her neonate asks the nurse, “Is it important for my baby to get colostrum?” When instructing the client, the nurse would explain that colostrum provides the neonate with: You Selected: • passive immunity from maternal antibodies. Correct response: • passive immunity from maternal antibodies. Explanation: Colostrum is a thin, watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies (e.g., immunoglobulin A). It is important for the neonate to receive colostrum for passive immunity. Colostrum is lower in fat and lactose than mature breast milk. Colostrum does not contain vitamin K. The neonate will produce vitamin K once a feeding pattern is established. Colostrum may speed, rather than delay, the passage of meconium. Remediation: Question 15 See full question On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do? You Selected: • Ambulate more often. Correct response: • Ambulate more often. Explanation: During the first few days postpartum, the accumulation of gas in the intestines may cause discomfort. This is relieved by measures such as increasing activity, doing leg exercises, avoiding carbonated or very hot or cold beverages, avoiding using ice or straws, and maintaining a high-protein liquid diet for the first 24 to 48 hours. A rectal tube also may be used. A gastric or intestinal tube is sometimes used when other measures fail. Simethicone tablets may provide some relief, but the nurse, not the client, should ask the primary care provider for this medication. Chewing on ice chips or using a straw may actually increase gas accumulation. Drinking hot coffee should be avoided because very hot or cold beverages increase gas accumulation. Remediation: Question 16 See full question While making a home visit to a multigravida 2 weeks after the birth of viable twins at 38 weeks’ gestation, the nurse observes that the client looks pale, has dark circles around her eyes, and is breastfeeding one of the twins. The client’s apartment is clean, and nothing appears out of place. The client tells the nurse that she completed three loads of laundry this morning. A priority need for this client is: You Selected: • fatigue related to home maintenance and caring for twins. Correct response: • fatigue related to home maintenance and caring for twins. Explanation: Remediation: Question 17 See full question The nurse is caring for a postpartum caesarean client and realizes that she has made a medication error. She administered intravenous morphine instead of intramuscular meperidine. What should be the nurse’s immediate action? You Selected: