Solutions
1. What is the first sign of hypovolemic shock from postpartum
hemorrhage?
a. Cold, clammy skin
b. Tachycardia
c. Hypotension
d. Decreased urinary output Correct Answers ANS: B
Tachycardia is usually the first sign of inadequate blood volume
1. What nursing assessment should be reported immediately
after an amniotomy?
a. Fetal heart rate is regular at 154 beats/min.
b. Amniotic fluid is clear with flecks of vernix.
c. Amniotic fluid is watery and pale green.
d. Maternal temperature is 37.8 C. Correct Answers ANS: C
Amniotic fluid should be clear. Green fluid indicates the fetus
has passed meconium, which is associated with fetal
compromise.
10. During a postpartum assessment, a woman reports her right
calf is painful. The nurse observes edema and redness along the
saphenous vein in the right lower leg. Based on this finding,
what does the nurse explain the probable treatment will involve?
a. Anticoagulants for 6 weeks
,b. Application of ice to the affected leg
c. Gentle massage of the affected leg
d. Passive leg exercises twice a day Correct Answers ANS: A
Anticoagulant therapy is continued with heparin or warfarin
(Coumadin) for 6 weeks after birth to minimize the risk of
embolism.
10. The initial vaginal examination of a woman admitted to the
labor unit reveals that the cervix is dilated 9 cm. The panicked
woman begs the nurse, Please give me something. What is the
most appropriate pain relief intervention for a woman in
precipitate labor?
a. Get an order for an intravenous narcotic.
b. Notify the anesthesiologist for an epidural block.
c. Stay and breathe with her during contractions.
d. Tell her to bear with it because she is close to delivery.
Correct Answers ANS: C
The nurse would stay with the woman experiencing precipitate
labor and breathe with her during contractions to help the
woman focus and cope with each contraction.
11. A woman who is 33 weeks pregnant is admitted to the
obstetric unit because her membranes ruptured spontaneously.
What complication should the nurse closely assess for with this
patient?
a. Chorioamnionitis
b. Hemorrhage
,c. Hypotension
d. Amniotic fluid embolism Correct Answers ANS: A
Infection of the amniotic sac, called chorioamnionitis, may
cause prematurely ruptured membranes, or it may be a
consequence of rupture because the barrier to the uterine cavity
is broken.
11. What statement by the patient leads the nurse to determine a
woman with mastitis understands treatment instructions?
a. I will apply cold compresses to the painful areas.
b. I will take a warm shower before nursing the baby.
c. I will nurse first on the affected side.
d. I will empty the affected breast every 8 hours. Correct
Answers ANS: B
Moist heat promotes blood flow to the area, comfort, and
complete emptying of the breast.
12. The nurse is administering terbutaline (Brethine) to a
pregnant woman to prevent preterm labor. The nurse would
assess for which adverse effect?
a. Maternal tachycardia
b. Maternal hypertension
c. Fetal bradycardia
d. Fetal hypokalemia Correct Answers ANS: A
, Maternal tachycardia is the common negative side effect of
terbutaline, which should be corrected with a dose of
propranolol.
12. What is the best response to a postpartum woman who tells
the nurse she feels tired and sick all of the time since I had the
baby 3 months ago?
a. This is a normal response for the body after pregnancy. Try to
get more rest.
b. I'll bet you will snap out of this funk real soon.
c. Why don't you arrange for a babysitter so you and your
husband can have a night out?
d. Let's talk about this further. I am concerned about how you
are feeling. Correct Answers ANS: D
If a postpartum woman seems depressed, it is important to
explore her feelings to determine if they are persistent and
pervasive.
13. The nurse is caring for a woman who had a cesarean birth
yesterday. Varicose veins are visible on both legs. What nursing
action is the most appropriate to prevent thrombus formation?
a. Have the woman sit in a chair for meals.
b. Monitor vital signs every 4 hours and report any changes.
c. Tell the woman to remain in bed with her legs elevated.
d. Assist the woman with ambulation for short periods of time
Correct Answers ANS: D