Ricci Chapter 16 - Test Bank - 4th Edition, OB final Exam ||
100% Faultless Solutions.
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: 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: 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: 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: 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: 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: 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.
7. The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an
Rhpositive
newborn based on the understanding that this drug will prevent her from:
A. becoming Rh positive.
B. developing Rh sensitivity.
C. developing AB antigens in her blood.
D. becoming pregnant with an Rh-positive fetus. Correct Answer: B
Rationale: The woman who is Rh-negative and whose infant is Rh-positive should be given
Rho(D) immune globulin within 72 hours after birth to prevent sensitization.
8. Which factor in a client's history would alert the nurse to an increased risk for postpartum
hemorrhage?
A. multiparity, age of mother, operative birth
B. size of placenta, small baby, operative birth
C. uterine atony, placenta previa, operative procedures
D. prematurity, infection, length of labor Correct Answer: C
Rationale: Risk factors for postpartum hemorrhage include a precipitous labor less than three
hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative
procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments,
prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention
,such as from a large infant, twins, or hydramnios.
9. When teaching parents about their newborn, the nurse describes the development of a close
emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The
nurse refers to this process by which term?
A. reciprocity
B. engrossment
C. bonding
D. attachment Correct Answer: C
Rationale: The development of a close emotional attraction to the newborn by parents during the
first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the
infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers
to the intense interest during early contact with a newborn. Attachment refers to the process of
developing strong ties of affection between an infant and significant other.
10. A nurse is reviewing the policies of a facility related to bonding and attachment with
newborns. Which practice would the nurse identify as needing to be changed?
A. allowing unlimited visiting hours on maternity units
B. offering round-the-clock nursery care for all infants
C. promoting rooming-in
D. encouraging infant contact immediately after birth Correct Answer: B
Rationale: Factors that can affect attachment include separation of the infant and parents for long
times during the day, such as if the infant was being cared for in the nursery throughout the day.
Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote
bonding and attachment.
11. A nurse is preparing a couple and their newborn for discharge. Which instructions would be
most appropriate for the nurse to include in discharge teaching?
A. introducing solid foods immediately to increase sleep cycle
B. demonstrating comfort measures to quiet a crying infant
C. encouraging daily outings to the shopping mall with the newborn
D. allowing the infant to cry for at least an hour before picking him or her up Correct Answer: B
Rationale: Discharge teaching typically would focus on several techniques to comfort a crying
newborn. The nurse needs to emphasize the importance of responding to the newborn's cues, not
allowing the infant to cry for an hour before being comforted. Information about solid foods is
inappropriate for a newborn because solid foods are not introduced at this time. The mother and
newborn need rest periods. Therefore, daily outings to a shopping mall would be inappropriate.
Information about newborn sleep-wake cycles and measures for sensory enrichment and
stimulation would be more appropriate.
12. When developing the plan of care for the parents of a newborn, the nurse identifies
interventions to promote bonding and attachment based on the rationale that bonding and
attachment are most supported by which measure?
A. early parent-infant contact following birth
B. expert medical care for the labor and birth
C. good nutrition and prenatal care during pregnancy
, D. grandparent involvement in infant care after birth Correct Answer: A
Rationale: Optimal bonding requires a period of close contact between the parents and newborn
within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal
care, and grandparent involvement are not associated with the promotion of bonding.
13. Which method would be most effective in evaluating the parents' understanding about their
newborn's care?
A. Demonstrate all infant care procedures.
B. Allow the parents to state the steps of the care.
C. Observe the parents performing the procedures.
D. Routinely assess the newborn for cleanliness. Correct Answer: C
Rationale: The most effective means to evaluate the parents' learning is to observe them
performing the procedures. Parental roles develop and grow through interaction with their
newborn. The nurse would involve both parents in the newborn's care and praise them for their
efforts. Demonstrating the procedures to the parents and having the parents state the steps are
helpful but do not guarantee that the parents understand them. Assessing the newborn for
cleanliness would provide little information about parental learning.
14. A postpartum woman is having difficulty voiding for the first time after giving birth. Which
action would be least effective in helping to stimulate voiding?
A. pouring warm water over her perineal area
B. having her hear the sound of water running nearby
C. placing her hand in a basin of cool water
D. standing her in the shower with the warm water on Correct Answer: C
Rationale: Helpful measures to stimulate voiding include placing her hand in a basin of warm
water, pouring warm water over her perineal area, hearing the sound of running water nearby,
blowing bubbles through a straw, standing in the shower with the warm water turned on, and
drinking fluids.
15. The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which
action would be a priority?
A. placing the call light within her reach
B. teaching her how the sitz bath works
C. telling her to use the sitz bath for 30 minutes
D. cleaning the perineum with the peri-bottle Correct Answer: A
Rationale: Tremendous hemodynamic changes are taking place within the woman, and safety
must be a priority. Therefore, the nurse makes sure that the emergency call light is within her
reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including
using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured.
The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can
be done once the woman's safety needs are met.
16. A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the
woman is at risk for a postpartum infection based on which information? Select all that apply.
A. history of diabetes
B. labor of 12 hours
100% Faultless Solutions.
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: 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: 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: 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: 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: 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: 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.
7. The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an
Rhpositive
newborn based on the understanding that this drug will prevent her from:
A. becoming Rh positive.
B. developing Rh sensitivity.
C. developing AB antigens in her blood.
D. becoming pregnant with an Rh-positive fetus. Correct Answer: B
Rationale: The woman who is Rh-negative and whose infant is Rh-positive should be given
Rho(D) immune globulin within 72 hours after birth to prevent sensitization.
8. Which factor in a client's history would alert the nurse to an increased risk for postpartum
hemorrhage?
A. multiparity, age of mother, operative birth
B. size of placenta, small baby, operative birth
C. uterine atony, placenta previa, operative procedures
D. prematurity, infection, length of labor Correct Answer: C
Rationale: Risk factors for postpartum hemorrhage include a precipitous labor less than three
hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative
procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments,
prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention
,such as from a large infant, twins, or hydramnios.
9. When teaching parents about their newborn, the nurse describes the development of a close
emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The
nurse refers to this process by which term?
A. reciprocity
B. engrossment
C. bonding
D. attachment Correct Answer: C
Rationale: The development of a close emotional attraction to the newborn by parents during the
first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the
infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers
to the intense interest during early contact with a newborn. Attachment refers to the process of
developing strong ties of affection between an infant and significant other.
10. A nurse is reviewing the policies of a facility related to bonding and attachment with
newborns. Which practice would the nurse identify as needing to be changed?
A. allowing unlimited visiting hours on maternity units
B. offering round-the-clock nursery care for all infants
C. promoting rooming-in
D. encouraging infant contact immediately after birth Correct Answer: B
Rationale: Factors that can affect attachment include separation of the infant and parents for long
times during the day, such as if the infant was being cared for in the nursery throughout the day.
Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote
bonding and attachment.
11. A nurse is preparing a couple and their newborn for discharge. Which instructions would be
most appropriate for the nurse to include in discharge teaching?
A. introducing solid foods immediately to increase sleep cycle
B. demonstrating comfort measures to quiet a crying infant
C. encouraging daily outings to the shopping mall with the newborn
D. allowing the infant to cry for at least an hour before picking him or her up Correct Answer: B
Rationale: Discharge teaching typically would focus on several techniques to comfort a crying
newborn. The nurse needs to emphasize the importance of responding to the newborn's cues, not
allowing the infant to cry for an hour before being comforted. Information about solid foods is
inappropriate for a newborn because solid foods are not introduced at this time. The mother and
newborn need rest periods. Therefore, daily outings to a shopping mall would be inappropriate.
Information about newborn sleep-wake cycles and measures for sensory enrichment and
stimulation would be more appropriate.
12. When developing the plan of care for the parents of a newborn, the nurse identifies
interventions to promote bonding and attachment based on the rationale that bonding and
attachment are most supported by which measure?
A. early parent-infant contact following birth
B. expert medical care for the labor and birth
C. good nutrition and prenatal care during pregnancy
, D. grandparent involvement in infant care after birth Correct Answer: A
Rationale: Optimal bonding requires a period of close contact between the parents and newborn
within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal
care, and grandparent involvement are not associated with the promotion of bonding.
13. Which method would be most effective in evaluating the parents' understanding about their
newborn's care?
A. Demonstrate all infant care procedures.
B. Allow the parents to state the steps of the care.
C. Observe the parents performing the procedures.
D. Routinely assess the newborn for cleanliness. Correct Answer: C
Rationale: The most effective means to evaluate the parents' learning is to observe them
performing the procedures. Parental roles develop and grow through interaction with their
newborn. The nurse would involve both parents in the newborn's care and praise them for their
efforts. Demonstrating the procedures to the parents and having the parents state the steps are
helpful but do not guarantee that the parents understand them. Assessing the newborn for
cleanliness would provide little information about parental learning.
14. A postpartum woman is having difficulty voiding for the first time after giving birth. Which
action would be least effective in helping to stimulate voiding?
A. pouring warm water over her perineal area
B. having her hear the sound of water running nearby
C. placing her hand in a basin of cool water
D. standing her in the shower with the warm water on Correct Answer: C
Rationale: Helpful measures to stimulate voiding include placing her hand in a basin of warm
water, pouring warm water over her perineal area, hearing the sound of running water nearby,
blowing bubbles through a straw, standing in the shower with the warm water turned on, and
drinking fluids.
15. The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which
action would be a priority?
A. placing the call light within her reach
B. teaching her how the sitz bath works
C. telling her to use the sitz bath for 30 minutes
D. cleaning the perineum with the peri-bottle Correct Answer: A
Rationale: Tremendous hemodynamic changes are taking place within the woman, and safety
must be a priority. Therefore, the nurse makes sure that the emergency call light is within her
reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including
using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured.
The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can
be done once the woman's safety needs are met.
16. A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the
woman is at risk for a postpartum infection based on which information? Select all that apply.
A. history of diabetes
B. labor of 12 hours
