NSG 3500
NSG 3500 - EXAM 3 QUESTIONS AND ANSWERS GRADED A+
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. - correct 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. - correct answer 1
,NSG 3500
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. - correct 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. - correct 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.
,NSG 3500
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. - correct 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. - correct 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.
, NSG 3500
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." - correct 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. - correct answer 4
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.
NSG 3500 - EXAM 3 QUESTIONS AND ANSWERS GRADED A+
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. - correct 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. - correct answer 1
,NSG 3500
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. - correct 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. - correct 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.
,NSG 3500
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. - correct 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. - correct 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.
, NSG 3500
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." - correct 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. - correct answer 4
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.
