4. The client’s insurance company will pay for the shot if it
2020 HESI OB/MATERNITY V 1 is given during the immediate postpartum period.
1. A 3-day postpartum client, who is not immune to 3. A patient, G2P1102, who delivered her baby 8 hours
rubella, is to receive the vaccine at discharge. Which of the ago, now has a temperature of 100.2ºF. Which of the
following must the nurse include in her discharge teaching following is the appropriate nursing intervention at this
regarding the vaccine? time?
1. The woman should not become pregnant for at least 4 1. Notify the doctor to get an order for acetaminophen.
weeks. 2. Request an infectious disease consult from the doctor.
2. The woman should pump and dump her breast milk for 3. Provide the woman with cool compresses.
1 week.
4. Encourage intake of water and other fluids.
3. The mother must wear a surgical mask when she cares
for the baby. 4. To prevent infection, the nurse teaches the postpartum
client to perform which of the following tasks?
4. Passive antibodies transported across the placenta will
protect the baby. 1. Apply antibiotic ointment to the perineum daily.
2. A 3-day-postpartum client questions why she is to 2. Change the peripad at each voiding.
receive the rubella vaccine before leaving the hospital. 3. Void at least every two hours.
Which of the following rationales should guide the nurse’s
4. Spray the perineum with a povidone-iodine solution
response?
after toileting.
1. The client’s obstetric status is optimal for receiving the
5. A 3-day-postpartum breastfeeding woman is being
vaccine.
assessed. Her breasts are firm and warm to the touch.
2. The client’s immune system is highly responsive during When asked when she last fed the baby her reply is, “I fed
the postpartum period. the baby last evening. I let the nurses feed him in the
3. The client’s baby will be high risk for acquiring rubella if nursery last night. I needed to rest.” Which of the
the woman does not receive the vaccine. following actions should the nurse take at this time?
,1. Encourage the woman exclusively to breastfeed her 3. “You must eat at least 3000 calories per day in order to
baby. produce enough milk for
2. Have the woman massage her breasts hourly. your baby.”
3. Obtain an order to culture her expressed breast milk. 4. “Many mothers lose weight when they breastfeed
because the baby consumes
4. Take the temperature and pulse rate of the woman.
about 600 calories a day.”
6. A breastfeeding woman has been counseled on how to
prevent engorgement. 8. A G2P2002, who is postpartum 6 hours from a
spontaneous vaginal delivery, is assessed.
Which of the following actions by the mother shows that
the teaching was The nurse notes that the fundus is firm at the umbilicus,
there is heavy
effective?
lochia, and perineal sutures are intact. Which of the
1. She pumps her breasts after each feeding.
following actions should the
2. She feeds her baby every 2 to 3 hours.
nurse take at this time?
3. She feeds her baby 10 minutes on each side.
1. Do nothing. This is a normal finding.
4. She supplements each feeding with formula.
2. Massage the woman’s fundus.
7. A 2-day-postpartum breastfeeding woman states, “I am
3. Take the woman to the bathroom to void.
sick of being fat. When can
4. Notify the woman’s primary health care provider.
I go on a diet?” Which of the following responses is
appropriate? 9. A client informs the nurse that she intends to bottlefeed
her baby. Which of the
1. “It is fine for you to start dieting right now as long as
you drink plenty of milk.” following actions should the nurse encourage the client to
perform?
2. “Your breast milk will be low in vitamins if you start to
diet while breastfeeding.” 1. Increase her fluid intake for a few days.
, 2. Massage her breasts every 4 hours. 4. Discuss the action of breastfeeding hormones.
3. Apply heat packs to her axillae. 12. The nurse is caring for a breastfeeding mother who
asks advice on foods that
4. Wear a supportive bra 24 hours a day.
will provide both vitamin A and iron. Which of the
10. The nurse in the obstetric clinic received a telephone
following should the nurse
call from a bottlefeeding
recommend?
mother of a 3-day-old. The client states that her breasts
are firm, red, and warm to 1. 1⁄2 cup raw celery dipped in 1 ounce cream cheese.
the touch. Which of the following is the best action for the 2. 8 ounce yogurt mixed with 1 medium banana.
nurse to advise the
3. 12 ounce strawberry milk shake.
client to perform?
4. 11⁄2 cup raw broccoli.
1. Intermittently apply ice packs to her axillae and breasts.
13. A breastfeeding mother states that she has sore
2. Apply lanolin to her breasts and nipples every 3 hours. nipples. In response to the complaint,
3. Express milk from the breasts every 3 hours. the nurse assists with “latch on” and recommends that the
mother do which
4. Ask the primary health care provider to order a milk
suppressant. of the following?
11. A multigravid, postpartum woman reports severe 1. Use a nipple shield at each breastfeeding.
abdominal cramping whenever she
2. Cleanse the nipples with soap 3 times a day.
nurses her infant. Which of the following responses by the
3. Rotate infant positions at each feed.
nurse is appropriate?
4. Bottle feed for 2 days then resume breastfeeding.
1. Suggest that the woman bottlefeed for a few days.
14. Which of the following statements is true about
2. Instruct the patient on how to massage her fundus.
breastfeeding mothers as compared
3. Instruct the patient to feed using an alternate position.
to bottlefeeding mothers?
2020 HESI OB/MATERNITY V 1 is given during the immediate postpartum period.
1. A 3-day postpartum client, who is not immune to 3. A patient, G2P1102, who delivered her baby 8 hours
rubella, is to receive the vaccine at discharge. Which of the ago, now has a temperature of 100.2ºF. Which of the
following must the nurse include in her discharge teaching following is the appropriate nursing intervention at this
regarding the vaccine? time?
1. The woman should not become pregnant for at least 4 1. Notify the doctor to get an order for acetaminophen.
weeks. 2. Request an infectious disease consult from the doctor.
2. The woman should pump and dump her breast milk for 3. Provide the woman with cool compresses.
1 week.
4. Encourage intake of water and other fluids.
3. The mother must wear a surgical mask when she cares
for the baby. 4. To prevent infection, the nurse teaches the postpartum
client to perform which of the following tasks?
4. Passive antibodies transported across the placenta will
protect the baby. 1. Apply antibiotic ointment to the perineum daily.
2. A 3-day-postpartum client questions why she is to 2. Change the peripad at each voiding.
receive the rubella vaccine before leaving the hospital. 3. Void at least every two hours.
Which of the following rationales should guide the nurse’s
4. Spray the perineum with a povidone-iodine solution
response?
after toileting.
1. The client’s obstetric status is optimal for receiving the
5. A 3-day-postpartum breastfeeding woman is being
vaccine.
assessed. Her breasts are firm and warm to the touch.
2. The client’s immune system is highly responsive during When asked when she last fed the baby her reply is, “I fed
the postpartum period. the baby last evening. I let the nurses feed him in the
3. The client’s baby will be high risk for acquiring rubella if nursery last night. I needed to rest.” Which of the
the woman does not receive the vaccine. following actions should the nurse take at this time?
,1. Encourage the woman exclusively to breastfeed her 3. “You must eat at least 3000 calories per day in order to
baby. produce enough milk for
2. Have the woman massage her breasts hourly. your baby.”
3. Obtain an order to culture her expressed breast milk. 4. “Many mothers lose weight when they breastfeed
because the baby consumes
4. Take the temperature and pulse rate of the woman.
about 600 calories a day.”
6. A breastfeeding woman has been counseled on how to
prevent engorgement. 8. A G2P2002, who is postpartum 6 hours from a
spontaneous vaginal delivery, is assessed.
Which of the following actions by the mother shows that
the teaching was The nurse notes that the fundus is firm at the umbilicus,
there is heavy
effective?
lochia, and perineal sutures are intact. Which of the
1. She pumps her breasts after each feeding.
following actions should the
2. She feeds her baby every 2 to 3 hours.
nurse take at this time?
3. She feeds her baby 10 minutes on each side.
1. Do nothing. This is a normal finding.
4. She supplements each feeding with formula.
2. Massage the woman’s fundus.
7. A 2-day-postpartum breastfeeding woman states, “I am
3. Take the woman to the bathroom to void.
sick of being fat. When can
4. Notify the woman’s primary health care provider.
I go on a diet?” Which of the following responses is
appropriate? 9. A client informs the nurse that she intends to bottlefeed
her baby. Which of the
1. “It is fine for you to start dieting right now as long as
you drink plenty of milk.” following actions should the nurse encourage the client to
perform?
2. “Your breast milk will be low in vitamins if you start to
diet while breastfeeding.” 1. Increase her fluid intake for a few days.
, 2. Massage her breasts every 4 hours. 4. Discuss the action of breastfeeding hormones.
3. Apply heat packs to her axillae. 12. The nurse is caring for a breastfeeding mother who
asks advice on foods that
4. Wear a supportive bra 24 hours a day.
will provide both vitamin A and iron. Which of the
10. The nurse in the obstetric clinic received a telephone
following should the nurse
call from a bottlefeeding
recommend?
mother of a 3-day-old. The client states that her breasts
are firm, red, and warm to 1. 1⁄2 cup raw celery dipped in 1 ounce cream cheese.
the touch. Which of the following is the best action for the 2. 8 ounce yogurt mixed with 1 medium banana.
nurse to advise the
3. 12 ounce strawberry milk shake.
client to perform?
4. 11⁄2 cup raw broccoli.
1. Intermittently apply ice packs to her axillae and breasts.
13. A breastfeeding mother states that she has sore
2. Apply lanolin to her breasts and nipples every 3 hours. nipples. In response to the complaint,
3. Express milk from the breasts every 3 hours. the nurse assists with “latch on” and recommends that the
mother do which
4. Ask the primary health care provider to order a milk
suppressant. of the following?
11. A multigravid, postpartum woman reports severe 1. Use a nipple shield at each breastfeeding.
abdominal cramping whenever she
2. Cleanse the nipples with soap 3 times a day.
nurses her infant. Which of the following responses by the
3. Rotate infant positions at each feed.
nurse is appropriate?
4. Bottle feed for 2 days then resume breastfeeding.
1. Suggest that the woman bottlefeed for a few days.
14. Which of the following statements is true about
2. Instruct the patient on how to massage her fundus.
breastfeeding mothers as compared
3. Instruct the patient to feed using an alternate position.
to bottlefeeding mothers?
